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HEALTH INEQUALITIES and IMPACT on the ECONOMY Northwest Regional Development Agency & NHS North West CONFERENCE REPORT

Report compiled by Pathways Consultancy Ltd

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CONTENTS BACKGROUND

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CONTEXT

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INTRODUCTION: Dr Ruth Hussey OBE. Regional Director of Public Health / Medical Director North West / Department of Health

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GLOBAL AND NATIONAL HEALTH INEQUALITIES REVIEW: Professor Sir Michael Marmot, University of Central London. Chair of the Strategic Review of Health Inequalities in England.

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COMMUNITY ACTIVISTS discussion with Sir Michael Marmot

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INTEGRATED REGIONAL STRATEGY: HEALTH and the REGIONAL STRATEGY: Simon Crawshaw: Director of Corporate Development and External Affairs. 4NW Tracy Mawson: Head of Strategy, Northwest Regional Development Agency

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DISCUSSION GROUPS on the NATIONAL HEALTH INEQUALITIES REVIEW & REGIONAL STRATEGY PRINCIPLES AND ISSUES PAPER

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INVESTING IN HEALTH: Maria Duggan: Northwest Investing4Health Advisor

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NORTH WEST HEALTH COMMISSIONS John Schultz, Chief Executive Stockport MBC & chair of Greater Manchester Health Commission Steve Maddox: Chief Executive Wirral MBC & chair of Cheshire & Mersey Public Health Network (CHAMPS)

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PLENARY & NEXT STEPS: Dr Ruth Hussey & Professor Sir Michael Marmot

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APPENDICES • Delegate list • Speaker biographies • Table discussions feedback to conference • Glossary

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FORWARD TO CONFERENCE REPORT ON THE MARMOT REVIEW OF HEALTH INEQUALITIES AND THE ECONOMY IN THE NORTHWEST APRIL 2009

The Partnership between the NWDA and NHS NW is vitally important to tackling inequalities in health across the region and to drive forward sustained economic growth. The Strategic Review of Health Inequalities in England, chaired by Professor Sir Michael Marmot, highlights the crucial role of the economy, employment and the built environment in tackling the poor health of the region. Creating the economic conditions in the region that transform the life and work opportunities of the people of the NW is an important objective for NWDA and is recognised by NHS NW as a key driver in delivering its own vision for better health, Healthier Horizons. Working together we can maximise the positive impact on health, deal with the concentration of ill health and tackle health inequalities that are present in the region. To this end the North West region is working closely with the Marmot Review as a pilot site for developing sustained approaches to reducing inequalities within the region. Improving health and tackling inequalities within the region is one of the underpinning values and principles of the new Integrated Regional Strategy RS2010 which the Agency is developing along with other regional partners. Health and well being will feature strongly in the strategy, in line with the growing body of evidence that shows that health and economic goals are mutually re-enforcing and vital to sustain economic wellbeing and inclusion within our communities.

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BACKGROUND The Conference on “Health Inequalities and Impact on the Economy” was sponsored by the Northwest Regional Development Agency and jointly organised with the NHS North West. The event was a result of the recently established Partnership Board set up by the two organisations to drive forward the joint agenda in relation to health, well being and a sustainable economy in the region. The purpose of the conference was: • to hear about the international and national work of Professor Sir Michael Marmot, from the World Health Organisation. Sir Michael chaired the Commission on Social Determinants set up by the World Health Organisation in 2005 and is now leading a review of health inequalities for the Department of Health. • to create the opportunity for discussion on the potential implications, regionally and locally, of the global and national work on health inequalities • to provide a collective response to the Northwest Regional Development Agency’s Principles and Issues Paper, which sets out the proposed framework for the Regional Strategy 2010? The aims of the conference were: • to look at the impact of health inequalities on the region’s economy; • to ensure alignment between key initiatives within the region such as Investing4Health; • to identify key actions for the North West in relation to health inequalities and advocate for their inclusion in the 2010 Regional Strategy • to create a movement for large scale change across the region. • to identify how the North West could link into the national review on health inequalities. Whilst it is acknowledged that this report is longer than would normally be required for a conference report, its timing, the aspirations and enthusiasm shared by speakers and delegates, the richness of the debates have been captured to share with colleagues across the North West, to strengthened engagement at a critical point in shaping future policy and delivery to reduce health inequalities.

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CONTEXT The impact that social determinants have on health and well being was clearly shown in the Black Report and the Health Divide1 which demonstrated that socio-economic circumstances play a major role in health differences. Building the evidence and translating this into policy and action across government, to make health everyone’s business has been a continual challenge. In recognition of the widening gap in health inequalities across England, the Government has taken steps through the Public Service Agreement targets to tackle health inequalities and some of the underpinning lifestyle causes such as smoking and childhood obesity. These are reflected locally through measures for the NHS and for partnerships through local area agreements where indicators for some of the wider social determinants are also included. The overall national target is to reduce health inequalities by 10 per cent, as measured by infant mortality and life expectancy at birth by 2010. The Department of Health have published new monitoring reports, based on ONS data for the period 2004 to 2006, detailing progress on the health inequalities targets for 2010 in three areas of infant mortality, life expectancy at birth for males and females and premature mortality rates relating to cancer and circulatory diseases. The reports show that: • for infant mortality the gap has decreased but more progress is needed to reach the 2010 target; • for life expectancy, the England average and spearhead life expectancy at birth has increased for both males and females but the relative gap between England and the spearhead group has widened – the gap is 2 per cent for wider for males and 11 per cent wider for females. • for premature mortality as measured by mortality from cancer and circulatory disease in people under 75, the inequality in cancer mortality has declined and the minimum reduction needed to meet the 2010 target has been achieved. The inequality gap in circulatory disease mortality has reduced and is on track to meet the 2010 target. Looking at the North West region, it has been possible to assess progress towards the health inequalities targets; using pooled data from the three years 2005 to 2007, compared to the baseline period 1995 to 1997. In all three categories of target – infant mortality, life expectancy, premature mortality for cancer and circulatory diseases – there has been a substantial improvement in the North West mortality figures; but that improvement has been relatively less than the counterpart improvement for England as a whole. In addition, about 64% of the North West population live in local authorities designated within the spearhead

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Townsend, P. Davidson, N. Eds. Whitehead, M. Author. 1988. “Inequalities in Health: the Black Report & the Health Divide.

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group; and the relative degree of improvement within these areas as a whole has lagged marginally behind the overall regional average. Consequently, health inequalities gaps have widened in the past ten years; both as between the North West Region and the national average, and also within the North West Region, between the more affluent and more deprived areas. These movements in geographical relativities, are however, comparatively small compared to the overall rates of mortality improvement. If we track relative indicators over time, we find that mortality gaps tended to increase between 1995-97 and 1997-99, then narrowed in the period 1997-99 to 2002-04, and have since tended to widen again. Some individual spearhead areas within the North West – notably Knowsley and Manchester – have however achieved much better improvements in mortality than the regional and national spearhead average in nearly all targeted categories of mortality, and are indeed on track to meet or exceed the 2010 target.

Health inequalities have historically been tackled through improving access to and availability of healthcare services2, through lifestyle behaviour change programmes3 and since Acheson4, a focus on inequalities in health outcomes (life expectancy and infant mortality). Whilst these have contributed to an overall improvement in health status, they are not impacting on reducing health inequalities. This may be due to the primary aim of healthcare services and lifestyle programmes to treat illness or improve health gain rather than being designed or delivered to have an impact on inequalities in health. The focus on health outcomes has detracted from the social determinants, where there is growing evidence that reducing the differential in health is influenced more by social determinants than by medical or preventative interventions. People’s experience of different health outcomes is due to factors other than biomedical or behavioural risk and are a consequence of political, social and economic structures that create inequalities in the living conditions which lead to health inequalities. These inequities in health arise because of the circumstances in which people grow, live, learn, work and age as well as the systems put in place to deal with illness. This inequity in health is thus rooted in social injustice. It is both avoidable and preventable but requires policies and programmes to influence the living conditions which are the determinants of health, with the engagement of civil society, to build social capital and social cohesion. In recognition of the increasing global health inequalities and social injustice, the World Health Organisation created the Global Commission on Social Determinants of Health in 2005. This was tasked with synthesizing international evidence on the social determinants of

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Over the last century only 10-15% of increased life expectancy in wealthy industrialised countries is attributable to improved healthcare. 3

Both the Black and Health Divide Reports argue that lifestyle behaviour choices are heavily dependent on socio-economic conditions people are living in.

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Acheson, D. 1998, “Independent Inquiry into Inequalities in Health Report” The Stationary Office.

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health and their impact on health inequity, and to make recommendations for action to address that inequity. The work was chaired by Professor Sir Michael Marmot.5 The Commission on Social Determinants of Health (CSDH) took a social determinants approach to health inequalities, seeing the unequal distribution of health-damaging experiences as a result of a combination of structural determinants (policies & programmes) and conditions of daily life making up the social determinants of health being largely responsible for health inequalities both within and between countries. The final report of the Commission, Closing the Gap in a Generation, sets out key areas of daily living conditions and of the underlying structural drivers that influence them in which action is needed. It provides an analysis of the social determinants of health and concrete examples of the types of action that have proven to be effective in improving health and health equity in countries at all levels of socioeconomic development. The Commission argues that for reasons of social justice, action to achieve health equity is imperative and that whilst health inequity between and within countries is related to levels of social disadvantage and inequality, it is not inevitable. The Commission shows that countries with more equitable policies and more just societies are healthier. The evidence analysed by the Commission shows that the lower an individual’s socioeconomic position the worse their health, so any attempts to reduce health inequity must be predicated on addressing the wider social and economic determinants, such as education, economic status, work and power relations. The CSDH Report also focuses on the gradient in health inequity. It argues that the focus of health needs be along the whole of the social gradient, i.e. that health follows the social gradient. Policies need to be designed which reduce the gradient by having proportionately more impact further down the gradient. A reduction in health inequalities will not be achieved only by focusing on people at the bottom of the social gradient. In the UK, the emphasis is on targeted interventions, for example in the spearhead group of local authorities with the lowest life expectancy. As health follows a social gradient, both universal and targeted policies and interventions are required to impact on health inequalities. The three overarching recommendations from the report are to: • improve daily living conditions • tackle the inequitable distribution of power, money and resources • measure and understand the problem and assess the impact of action The Global Commission also encouraged national governments to develop and implement strategies and policies, tailored to their specific national needs. In response to both this recommendation and to the persistent health inequalities, the UK Government has set up the Strategic Review of Health Inequalities in England, chaired by Professor Sir Michael

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World Health Organization, Commission on Social Determinants of Health, 2008. “Closing the gap in a generation: Health equity through action on the social determinants of health”.

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Marmot. This will report to the Secretary of State in December 2009 and inform the development of a post 2010 health inequalities strategy, which will include policies and interventions that address the social determinants of health inequalities.

INTRODUCTION The conference was opened by Dr Ruth Hussey OBE, by emphasising that the purpose of the event is to hear delegates’ views on both the national health inequalities review and what needs to be included in the emerging Regional Strategy to impact on health inequalities in the North West. The Northwest Regional Development Agency‘s sponsorship for this event is welcomed as recognition that the Regional Strategy (RS2010) must address the health and well being of the population. This is a critical time globally, nationally and locally, with the day providing an opportunity to foster a real understanding that “there is no health without wealth, and no wealth without health” and both are intimately intertwined. The event is an opportunity to shape the vision and future we want in the North West, building on best evidence available across the globe today and to look at how we deal with current and future challenges. In terms of where are we now in the region, taking life expectancy as a measure for health, whilst there has been an overall improvement for the region, the gap between the North West and England continues to widen as does the gap in some places within the region. There has been some improvement through better care, and the NHS has taken a key part in properly meeting the needs of people, for example through the cardio vascular programme, and this region has pioneered curbing tobacco use and continues to champion the smoke free agenda. But as these benefits are accruing the region is being overwhelmed by the impact of alcohol on the health of people in the region. We have the highest hospitalisation rates in England and see alcohol as one of the single signals that all is not well. However, these are symptoms but we need to look beyond that. There are areas where there has been insufficient attention paid, one of which is mental health. People with severe mental health problems die 10 years younger than others – to be healthy needs good mental health. The “5 ways to well being” 6 should thread through all our work and thinking. As a region we need to continue to ensure that services are available to all. Evidence shows that services are not consistently available and delivered to all at the same standard, so there is also a quality aim. We should put aside the phrase “hard to reach groups” and be talking about “hard to reach services” with it being everyone’s responsibility to make sure services are accessible and meet everyone’s needs. This aspiration will be supported by the

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Foresight, Government Office for Science, 2008 “ The Mental Capital and Wellbeing Report”

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NHS North West’s recently published Equity and Diversity Plan for Action 7 and the Northwest Regional Development Agency’s Single Equality Scheme8 . We need to continue our work on lifestyles, positioning our understanding more deeply in what it is that influences people’s lives and behaviours. We know through the obesity work that it is the obesogenic environment which has led us to where we are. We need to consider how we shape the society we aspire to, that will create best health. Our children are not born binge drinkers; we have created a society that has created the phenomenon of binge drinkers and we have a shared responsibility in its production. Are we focused in the right place? Are the right questions being asked to make a transformation in health and well being? We look at services, we look at lifestyles and acknowledge that there are some areas where we are not doing enough such as mental health. What else should we be looking at? This is where the global report on social determinants of health and Sir Michael’s work on the causes of the causes play a critical part in our thinking; going beyond the biomedical and lifestyles and looking at how we have created a society which has produced some of our ill health. As a regional we have been tackling health inequalities for some years, it has been the golden thread through our work. This will be further supported by the establishment of a Centre for Transformation of Health and Well Being. This will help to build the evidence base and support the translation of theory into practice with better approaches and interventions to secure the transformation we are looking for. We are on a journey to recovering good health, to ensure everyone has good health in the region. It is there for everyone to claim and we all have a responsibility to strive to secure the best health we can for future generation.

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NHS Northwest, 2009. “Equity and Diversity Plan for Action

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Northwest Regional Development Agency, 2008 “ Single Equality Scheme”

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Health Inequalities Review: Taking Action on the Social Determinants of Health. Professor Sir Michael Marmot The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organisation and had as its starting position that individuals, lifestyles and services are not enough. They don’t explain the mal-distribution of health within countries and between countries. The object of the Commission’s work was to collate the evidence of what can be done to take action on the social determinants of health. The Commission had two mantras: “that evidence matters” and the “importance of social justice”. The final report was called “Closing the Gap in a Generation”, because it gave a statement that we have the knowledge and the instruments potentially to close the health gap in a generation but the question is whether we have the will to do it? The Commission put empowerment at the heart of what it was attempting to do empowerment of individuals, communities and whole countries. It thought of empowerment as material - is there enough food; psychosocial – having control over your life and political having a voice. It is through empowerment that conditions are created for people to lead flourishing lives. The question is how to do it? Having a value of social justice is not enough, it has to be put into place. In the Report there are identified areas for action: •

Improve daily life: improve the conditions people are born and develop in, live and work in, which includes early child development and education, fair employment, social protection and universal healthcare.

Tackle the inequitable distribution of power, money and resources (the structural drivers for daily life) – the inequalities in money, power and resources which require health equity in all policies, gender equity, political empowerment, inclusion and voices, market responsibility and fair financing.

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Measure and understand the problem and assess the results of action: acknowledging that there is a problem and ensuring that health equity is measured, within countries and globally, is essential for action.

Implementing the recommendations The question is what is going to happen to the Report – how can the CSDH recommendations be translated into different country’s contexts? What is it going to mean for a country, regions and local areas? How can a set of global recommendations be translated into the local context? A small number of countries have been invited into a partnership and whilst considering the UK National Review and this conference, the North West will be invited to become a regional partner in the National Review. The whole idea being that when the review is finished and the report published, will anything happen? By having partners in the Commission and the National Review things will happen. This offer of partnership in the Commission has been taken up by Brazil, there have been conversations with India for a number of states to be partners and possibly Sri Lanka at some point. At the London “Closing the Gap” Conference in November 2008, which launched the Global Report, the Prime Minister announced his intention to undertake a review of the health inequalities in England and “that we will learn from other countries along the way”. The Secretary of State for Health asked me, “to lead a review, based on the best global evidence, on how we can do more to tackle health inequalities in this country”. The Commission’s Approach The approach used by the Global Commission was to gather best evidence by setting up nine global knowledge networks and engaging with civic organisations. It is proposed to use a similar approach for the national (England) Review. In dealing with health inequalities we have to look at the causes of illness but also the “causes of the causes” and have to deal with social inequalities. For the Strategic Review of Health Inequalities in England – the “Marmot Review”, there are 4 terms of reference, which have been framed into tasks with separate committees. •

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The first committee will follow a similar model to the Global Commission with nine task groups to look at evidence relevant to future policy and actions. Interim reports have been already been produced (April 2009). The second committee is to recommend objectives and measures for 2010 and beyond 2020, looking at the medium and long term. A third committee is looking at how to turn evidence into practice and is due to report in September 2009 The fourth task is to publish a final report of the review’s work with recommendations, which will contribute to the development of a post 2010 health inequalities strategy by December 2009.

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The nine Task Groups are: • Early child development and education • Employment arrangements and work conditions • Social protection • Built environment • Sustainable development • Social exclusion and social mobility • Priority public health conditions • Economic analysis • Delivery systems The following gives a brief flavour of some of the evidence from the Task Groups: 1. Early child development & education: • Survival & development in early childhood is a big issue when thinking globally but even in the poorest countries we need to be thinking about the quality of infants’ health as well as infant mortality. • Physical, language/cognitive and social/emotional development: evidence shows that socio-economic status matters enormously to cognitive development especially in babies over 22 months9 . • Sure Start makes a difference: when comparing areas with local programmes and areas without, child positive social behaviour is better, negative parenting less, and the home learning environment improved in areas with local programmes • There is evidence that Key Stage 4 attainment is affected by income.10 A whole debate is needed between universal and targeted interventions. If we only target the worst ten per cent, only focusing on the bottom, the next ten per cent above are missed. There is not only a health gradient but evidence that health follows the social gradient, for example Key Stage 4 attainment is one marker in education that follows the social gradient. 2. Employment arrangements and work conditions: Evidence shows that those with secondary education have higher unemployment rates than those with tertiary education11. The numbers of unemployed follows the social gradient and the current recession will hit the less educated and less skilled more. All crisis effect people differentially depending on where they are in the hierarchy, the closer you are to the bottom the more likely you are to be effected. This became a real issue in the 1980’s unemployment crisis.

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Feinstein, Economica, 2003

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Department for Children, Schools and Families, 2007 in “Aspirations and Attainment in Deprived Communities” Cabinet Office.

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“Unemployment rates by level of education in UK” Education at a Glance, 2008 OECD

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There is also a clear social gradient in the mortality of men aged 16-64 years by social class and employment status12. The lower down the hierarchy you are the higher the impact on health. Unemployment is bad for everyone, but worse for the lower social classes. The impact on their health will be worse.

3. Social Protection throughout life Low living standards are a powerful determinant of health inequity. Professor Jerry Morris13 calculated the minimum income for health living - (healthy diet, physical activity/body and mind, psychosocial relations, mobility, medical care, hygiene and housing) for a pensioner over 65 years, is £135 a week and is not provided by the level of state pension for single person currently at £85. The state pension does not give people who are dependent on it enough for a healthy life. One of recommendations from the review will be to provide the rationale basis for social protection, for pensions and other benefits. 4. The Built Environment Whilst the quality of housing has been improving there is still a substantial proportion that is not decent and there is a differential between private rented, social rented and owner occupied14. 5. Sustainable development Sustainable development sets the context for this agenda, though the case that action on sustainable development will impact on health inequalities does not seem compelling by itself. What is compelling is when considering taking social action to reduce health inequalities; this has to be done in the context of sustainable development, taking into account thinking what kind of society we want in the future. We should be asking how policies aimed at mitigation and adaptation affect the social determinants of health and health equity and vice versa. 6. Social exclusion and social mobility External events always affect those of the lower social class more. For example in the heat wave in Europe (2003) it was the elderly, those with less autonomy and the socially isolated who suffered15.

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1981 LS Cohort “England and Wales mortality”, 1981-92

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Morris JN et al. (2000) A minimum income for healthy living. Journal of Epidemiology and Community Health, 54: 885-889 14

The proportion of homes measured as non-decent by tenure from English House Condition Survey www.poverty.org.uk. 15

Brucker, 2005. Vulnerable Populations: Lessons learned from the Summer 2003 heat waves in Europe. Euro Surveill10 (7) p. 147

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7. Priority Public Health conditions The review did not want to forget public health conditions such as smoking, obesity & alcohol. One public health condition the task group included was mental health. The prevalence of mental health/ill health by household income from the Health Survey for England16 shows a clear social gradient as does the prevalence of obesity among adults by income quintile where the social gradient is more evident in 2006 than it was in 1998. The social gradient for women is clearer showing that obesity affects people differentially. 8. Economic Analysis One criticism of the Global Commission Report was that it did not do an economic analysis to show the benefit to the economy of reducing health inequalities and that as a consequence the report would not be taken seriously. This idea was resisted, with the view being held that “it is the right thing to do – it’s social justice”. Health and well being is an entitlement and a moral issue and that if there is an economic benefit then that is a bonus. Economics is not the overriding factor and that if we know what needs to be done to reduce the social gradient and yet are not doing it then that is surely unjust. However, the Task Group did have a look at cost effectiveness to see which interventions were more cost effective. What is happening to income inequalities? In the UK earnings for men and women in fulltime employment have been growing (1980-2003) but growth has been higher for those earning more than for those on lower incomes. The increase has been bigger for women than men so there has been some catching up but there is some way to go. Income inequality for full time employment has increased although everyone has improved. In the USA everyone below the median income got worse. What is happening to income inequalities is key to health inequalities and key to the health of the overall population.

9. The Delivery System We don’t think that the major reason for health inequalities resides in the healthcare system. That said the healthcare system is important. Universal access to high quality healthcare has to be fundamental and to the extent that there are problems in UK, they have to be addressed. For example the number of GPs per 100,000 weighted population by area deprivation17 shows that there are more GPs in least deprived areas and fewer in most deprived areas so even though we have universal health service, free at the point of access, we still haven’t solved the maldistribution. Questions to leave the conference with:

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Health Survey for England, 2006. ONS. London

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Department of Health, 2007. Tackling Health Inequalities

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1. Should the action be central, regional and local? The answer has to be yes, but what should it look like and how should we get the levels together? 2. Universal versus targeted: Health follows the social gradient. There is a clear debate to be had. Should we be targeting only those most in need? Why give benefits to those who don’t need them? The other side of the argument is having a health system for the poor is a poor health system and the same for education. Through universal benefit everyone benefits across the social gradient. 3. Every sector is a health sector – every minister is a health minister. We have to think of health and well being outcomes in terms of what happens in transport, finance, education, the environment etc. 4. Ruth made the point that we have to get the narrative right. In the report we want to give practical recommendations but also to ask what kind of society do we want? 5. What would success look like? Would it be the adoption of social determinant policies across government and by opposition parties? 6. A social determinants of health strategy needs to be supported by public agencies and civic society and where the civic society takes ownership of programmes on social determinants 7. What would a real outcome be? Would it be a world where social justice is taken seriously?

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Q&A Q: Warrington Council of Faith How long will it take to narrow the gap between countries of high deprivation and those less deprived? Response: Sir Michael We use this expression of narrowing the gap in a generation advisedly. Let’s start right at the beginning of life with girls who will grow up to be women, mothers and adults. We do need to be looking at this on a global footprint, the G20 is an advance on G8 but what really need is G193, so where are other countries? Global arrangements really matter and so does governance. Discussions are taking place with the World Bank to see how they can influence the African countries to adopt the Global Report recommendations. If governments can’t or won’t act then organisations have to act. There can be help from outside but essentially needs to be social action at grass roots. Q. Access Matters Whilst pleased to see mental health getting more profile but we have to lobby for an increased focus on morbidity than mortality and for muscular skeletal conditions, which are probably the largest single cause of unemployment across Europe, needs to be profiled in the Review. Living with chronic condition is damaging for individual and family but hugely damaging for the economy Response: Sir Michael The Global Commission was concerned about covering too much superficially. The aim was to set the framework. Mental health, chronic illness and disability are very much within the Commission’s focus. More flexible working for people with chronic illness is needed as it is becoming harder for people to have a relationship with the workplace because of policies. Keep lobbying, keep pushing. Q: Liverpool City Council You have raised issues about universal and targeted interventions which is a big question and is there something around the framework or the policy being universal. On the issue of GPs, Everton took ten years to get an increase in GPs in the area but is still behind the less disadvantaged. There is an issue about targeting it terms of building up and strengthening the protective factors so that they don’t get over run by the risk factors, so there has to be some targeting. 16


Response: Sir Michael What you said is a way of resolving it. We want a society where these inequalities are less. For example look at education inequalities and international comparisons of literacy and looking at literacy by parent’s education. There is a very steep gradient in this country and very shallow gradient in Sweden and Japan. This has got to be soluble by reducing levels of inequality in society. We are blessed with a NHS because it’s a universal system. It is a statement about society that says we may need to have special action to bring people into a progressive universalism and there are exclusions but to see it as having a service for specifically disadvantaged group is a very limited way forward.

Summary Note of Meeting with Community Activists This discussion group took place before the main conference with an invited group of community activists from across the North West. The group then joined the conference. Michael Marmot summarised the outcome of the WHO Report ‘Closing the Gap in a Generation’ and explained the connection with civic society representatives who both provided evidence and posted solutions to addressing health inequalities. Comments from the community members emphasised the difficulties in engaging with statutory services and organisations. There was a perception that activity was supported in top down rather than bottom up initiatives. Sometimes, when in frustration activists bypass the system and this can result in them being pigeonholed as an agitator. Community analysis of problems and generation of solutions was needed in an approach which fosters community decision making. This requires nurturing and community development. A social justice orientated strategy was pertinent addressing income inequality which creates stress and anxiety. A shift was needed into person and community centred planning. Commissioning in public sector should be rooted in community development principles treating causes rather than symptoms. This potentially raised tensions between national policies and initiatives and local self determination and evaluation of the added value of initiatives such as Sure Start. A cultural problem was emphasised in creating effective partnership between local groups and communities and public authorities with a sense that power needed to be given and grasped if the journey together was to ensure communities took control. The gap in equality was the issue with the average improving faster than the worse off. This in turned raised issues of universal and targeted interventions which requires detailed consideration.

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Simon Crawshaw: Director of Corporate Development and External Affairs 4NW 18 Simon outlined the context for the Regional Strategy and the Principles and Issues Paper which will underpin this regions’ Regional Strategy. The first point is about the timing - why now? There are two key issues: • Why, when there is a global recession, are we setting our stall out now? It is precisely because of the recession that the time is right because the document is about how this region will emerge from the recession, more competitive, more dynamic and able to champion its competitive advantages. • The second point on timing is why not be the first region to develop its Regional Strategy? We would rather set out what we want in our strategy (which is the first of this type) rather than follow other regions. We would rather we made our own mistakes and learn from them, than follow mistakes of other regions. Actually we have a heritage in this region of getting it right and with our two organisations working together to co-produce this Strategy, this will provide a powerful vehicle to create a strategy on behalf of the region, that belongs to the region and reflects the interest of the region. The second point is an appeal. Referring back to Ruth’s phrase: “there is no wealth without health, and no health without wealth”; the appeal is that when looking through the Principles and Issues paper, not to look for the number of mentions of health in the document as it’s my contention to the delegates is that there is nothing in the document that isn’t about health. This is a holistic document and contains health within it. It is far too simplistic to count the number of mentions but what is needed from delegates is to fill up this framework with what it needs to contain to champion health in the North West The final point is approach and how the Strategy is being approached in this region. There are different ways of approaching a Strategy. The Principles and Issues paper actually contains the assumptions for the Strategy. The approach could be likened to setting out area for virgin parkland. There are two options: that the policy people could lay it out and then carryout a consultation to prove what they have proposed is right or a second approach

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4NW is the Regional Leaders Forum – the successor body to the Regional Assembly

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which is to leave grassland alone for a while and see where people want to walk and look for where the natural linkages occur, and then build on that framework.

The Integrated Regional Strategy – Health and the Regional Strategy Tracy Mawson: Head of Strategy – NWDA Tracy confirmed that the conference delegates and health colleagues are key stakeholders in the Regional Strategy and that the twelve week consultation on the Principles and Issues Paper is now coming to an end. The consultation has gone out widely and diversely over the three month period. There is a very different regional architecture with a different approach to development of this Regional Strategy from the previous regional economic strategy, a change which was signalled by the Government in its review some eighteen months ago. By bringing together all the planning and economic investment sectors, the Regional Spatial, Economic and Housing strategies will be integrated into a Single Integrated Regional Strategy which will have a more logical and consistent approach, and more crucially have more integration of social factors and with health stakeholders. The Government is currently putting together legislation to enable all regions to produce a Regional Strategy so the North West is currently working on the old planning guidance, so it is challenging from both a political and legislative perspective. The Timeframe The first stage of the Principles and Issues Paper started in February 2009 and finishes April 30th 2009 with submissions invited either individually or as organisations. There have been calls for evidence throughout 2008 and this work continues with further new work to be commissioned. There will be a report on the consultation in early June, which will indicate the next steps, followed by development of the Strategy with detailed implementation and actions. There will be another three months of consultation at the end of the year (December 2009) before submission to Central Government. Throughout the process there will be a number of impact assessments including health and equality. The main purpose of today’s event is to ask you to think about content of the Principles and Issues Paper. The document makes a number of assumptions, which you may or may not agree with. For example, that we won’t see a large move towards working at home over next ten years and that people will still need to commute to work and travel around region. Do you agree with this? The point of the strategy is not to write a section for each sector or place but to set out a framework which describes: • What is the vision for the North West? • what are its assets? • what are the unique factors in combination? • what makes it a special place? 19


• what will give people quality of life? • It also goes through some of the challenges – includes health, deprivation, inequalities and some newer ones like climate change. The goals for the Regional Strategies have already been set by Government, in that Regional Integrated Strategies need to be developed in the context of sustainable economic growth and that the Strategy must contribute to sustainable development. The Strategy will also need to contribute to the mitigation of, and adaption to, climate change. The document also gives definition to achieving longer term “sustainable and equitable social, economic and environmental wellbeing” integrating social, economic and environmental issues, rather than just focusing on Gross Value Added. There is an opportunity within the document to say what sustainable economic growth means to the North West, how should sustainable economic growth be defined, what are the goals and how could they be measured? From this event what should the Regional Strategy say? How spatially specific should it be? What are the particular indicators of ill health and how should the specific health parts of the strategy to be phrased? What is the direction for the North West and how should it be measured? From the evidence base to date, the Northwest Development Agency and 4NW have drawn up a set of ten issues, in relation to the principles, described in the Principles and Issues Paper. The question posed is if the NW prioritised this issue, does it adequately described what you want to see? •

Climate change and resource use: there is a need to improve the way we use our resources, not just energy and food, but for example the production and management of our waste. There are stretching carbon reduction targets nationally, so how will the North West contribute to these. Our industry and business footprint is quite a high carbon footprint but there are opportunities for development of clean energy and opportunities for innovation, science base and developing research capabilities. Growth driven by cities and towns: economic wealth and increasing jobs has been focused on cities and towns. Do we want that to happen in future? Where will people work and live and if planning for this how this should be done sustainably. What are implications for travel and the links to healthy workplace? There are practical infrastructure issues around electricity and the impact of climate changes. Connectivity: this is about physical and digital connectivity. How do we plan for increased digital connectivity? How do we ensure a sustainable transport infrastructure? How do we de-carbonise travel and invest in electric trains for example. Are our ports, airports and rail systems being maximised and are we dealing with areas of poor provision? Places and Communities: this Strategy moves on from the economic strategy to being more spatially aware. It needs to give clarity on the future strengths of places and their inter-relationships, enabling places to evolve different roles. It needs to say how places and communities can react to change and develop capacity to become more self sustaining in the future, within the context of reduced investment. 20


Natural environment and rural areas: previously the environment was somewhat lost between the regional economic and regional spatial strategy. It is very clear that environmental protection and enhancement need to be within this Strategy, both protecting our assets but also improving places where needed. Rural areas need a plan to enable people to access services and jobs as well as making the most of our outstanding natural environment. The Strategy needs to build up the rural economy and quality of life through a stronger food offer. Skills and talent: the people of the region determine what type of region it is. The region needs to develop, attract and retain talent and creativity with greater innovation and leadership at all levels, which supports communities. This requires an appropriate educational infrastructure and a supply of good housing to ensure that there is no increase in deprivation. Health and worklessness: the relationship between ill health, health inequalities and worklessness is clear and has not significantly improved for a number of decades. The region needs to have conversations about how it works on this persistent challenge, tackling the causes rather than the symptoms. The outcomes experienced in particular places have not changed and whilst some regeneration programmes may have helped individuals they have not significantly changed the outcomes and so not justified investment. These intractable outcomes the region faces with ill health and worklessness and raising aspirations need challenging. Innovation: the region has strengths in science, Research & Development, and the size of Higher Education base, with a heritage of innovation and creativity. We need to encourage more people to study STEM (Science, Technology, Engineering and Maths) and to keep people with these skills in the region. Advanced manufacturing: we have learnt through the recession that services need to give way to production whether digital or physical production. The North West is well positioned with clear strengths in advanced manufacturing. Nature of growth and the role of the public sector: there is a need to think about what our sustainable economic development goals are and we can tactically use the public sector to achieve them. Through learning and horizon scanning to correctly build capacity and the way we spend and procure.

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Table Discussions: Q1: What would you wish to see in the national report that would assist you in delivering a reduction in health inequalities? Emerging themes from discussions The national report provides the opportunity to articulate what kind of society we want and to create a public service ethos which is not economically based. The national review provides an opportunity to take a more positive approach to health and well being and quality of life. Social determinants need to be explicit for each organisation and their contribution defined. The Report should support integrated working on social determinants and to spell out what this would mean at borough level, articulating a social determinant approach for Local Strategic Partnerships (LSPs) and community partnerships. There is also a need to make social justice a credible driver which requires a mind shift and transparency. This would necessitate a different approach to measuring outcomes. Government needs to set measurable targets for agencies that capture their specific contribution and responsibility for delivery, demonstrating collaborative working. However, indicators do need to be more flexible and not create perverse incentives. When planning delivery and whether this should be universal or targeting, it is not an either or, but needs to follow the social gradient especially for children and young people. Services need to be universal but with a differentiated response along the gradient. More evidence is needed on the either or both approaches. How services are marketed when specific groups are targeted could help the understanding and appreciation of why a specific approach is being used. Further research is required on the relationship between health, economic development and sustainable development and that challenges the widely held assumption that economic growth is necessarily beneficial. A shift of focus in the research to people as individuals and what works for them rather than place is needed. The national report should emphasise the need for communities to be involved and empowered, to strengthen social networks and social cohesion with local organisations, voluntary and the 3rd sector having a defined remit to influence social determinants: More 22


local control over decisions will provide increased cohesion and resilience especially during periods of recession. This would generate more personal responsibility which involves resilience and confidence. Using healthcare requires confidence and we need to understand this better. There is a need to develop programmes that bridge communities and develop social capital: “ we feel the national report needs a programme delivery that provides bridging for social capital and enabling people from different groups to appreciate and value each other “ The Report should address ways to change the culture of the public sector so that local community knowledge is valued and maximised, and the interface between local and national is strengthened, both working to create an environment for local solutions, through community centred planning. There is a power relationship between sectors and local people which needs to be rectified. Local voices need to be heard – and stories told. This collaborative approach from national to local will require clarity about roles and responsibilities centrally, regionally and locally with consensus on what’s best delivered by whom. A toolkit attached to the report could support the translation and understanding of the national recommendations into local action. The Report should put more emphasis on partnership working at borough level through LSPs where the leadership needs to happen to address “the causes of the causes”. The NHS is driven by different set of priorities. Making the economic case for addressing “the causes of the cause” will be needed in order to persuade people. Quantitative modelling is required which shows the positive benefit outweighs the negative costs. The economic case has to be made and the next Comprehensive Spending Review influenced. There is a debate about “the right thing to do” and if it has a positive or negative impact on the economy. A key issue is whether it can be quantified. There is a cost to the country to redress health inequalities. Both income inequalities and environmental inequalities impact on health and well being. What is the something else, over and above reducing income inequalities that we should do particularly as income can’t explain all the differences? The Benefits system is moving in the right direction but its needs more radical change away from being punitive to being more flexible and empowering facilitative system for people with long term conditions and carers A number of specific issues were raised in discussions which should be included in the Report. More emphasis should be given to housing and health, both through mechanisms and targets. Currently there is no formal accountability, which could be strengthened by joint targets. Older people should be recognised as a resource, contributing to social networks. Support is needed for prioritisation of early years and child development. Workplace health also needs to be included. [Feedback points to the conference: Appendix 3] 23


Q 2: What are the key health and wellbeing actions that you would wish to see in the NW Integrated Regional Strategy Emerging Themes from discussions: The Regional Strategy is an opportunity for all partners to contribute to the social determinants of ill health, “the causes of the causes”, as there is a shared responsibility about having created a society which has produced lifestyles 19which contribute to ill health, such as alcohol consumption, smoking, poor diet and physical inactivity and obesity. The role and contribution of all partners should be clearly articulated and actions on social determinants linked to measures of health equity. There was a collective response that the Regional Strategy needs to reflect its role in ensuring social justice and that social justice should be given equal weight to economic development rather than be subsumed by it. The importance of values were expressed in various ways by conference delegates and that economic growth should not been seen as an end in itself, with further research proposed to explore the benefits of economic growth. The overall response to the contents of the paper was that health and social inclusion should be more explicit throughout the document with health being defined in terms of creating well being across the region rather than in terms of sustainable economic growth. The Strategy provides an opportunity to profile health and wellbeing, with more of a balance being expressed in the paper between economic elements and social capital, social justice and health and well being. The Strategy needs to set a clear direction about what is the shared ambition for the region and how it interprets sustainable economic growth and the degree to which this is about GDP or quality of life and social capital. It was suggested that more consideration be given to the social elements of economic growth than is currently demonstrated in the Principles and Issues paper. There is a real challenge in both the development and implementation of the Strategy in its translation from national and regional aspirations to regional and local delivery, giving more local and community control. This raises questions about how it is decided that the Strategy is “doing the right things at the right level”.

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Dr Ruth Hussey – from the conference Introduction

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Integration and collaboration was a common theme from the delegate discussions. This was partly about integration and inclusion of health and well being throughout all policies, providing “the golden thread” through planning, policies and processes throughout all sectors. The Strategy needs to include actions which reflect an integrated approach and measures of their impact, at the appropriate level whether regionally, sub regionally and locally. It was felt there are still barriers to integrated, collaborative working which need to be analysed and effective practice for collaborative delivery identified and made more visible. People are at the core of the Principles and Issues Paper, “their health, talents and quality of life ...will define our region, our businesses and our communities”.20 This principle was reflected by a number of the delegate discussions. People are the assets of the region and this should be maximised to create mixed economies and communities, with actions that encourage developing people’s self esteem, identity and fostering a sense of believing and belonging. Building social capital and social networks should be integral to the Strategy, including volunteering, being recognised as of equal value to economic growth. The Strategy needs to reflect a wider appreciation of public value and have the debate as to whether the aspiration for the region is quality of life or GDP per head of population. Building aspirations was a common theme in discussions. How best to build the aspirations of individuals, communities and business so that they can be better engaged. The Principles and Issues Paper was not explicit about where individuals feature when talking about regional aspirations. The Strategy could include actions which will influence individuals, communities and business’ aspirations reflecting the vision of the Strategy. This could be specifically developed with business’ considering their corporate social responsibility role as well as profit, with some incentivisation and reward for engagement. The importance of the process of developing and delivery of the Regional Strategy was reflected in a number of ways by delegate discussion, including the need to have a step change in partnership working, more effective integrated and collaborative delivery with true engagement of local communities and individuals.

Specific comments from discussions: Principles

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A Regional Strategy needs to contain actions that reflect the needs of our communities in a language that can be understood with actions to build more capacity in communities.

Collaboration needs to be made more visible and demonstrated in the strategy and communicated to diverse communities. More collaboration with stakeholder

Northwest Development Agency, 2009 Regional Strategy Principles and Issues Paper. 2.3. p.4

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particularly in deprived areas with the use of social marketing principles and local champions. •

Leadership at strategic level is needed which is visible and listens to local voices.

How do we invest locally to support local economies? The Regional Strategy needs to invest in the “need in the middle” not necessarily the most needed, i.e. follow the social gradient. How do we reach the “poorer” people within communities?

A narrative is needed that tells a story reflecting people’s experience of how it is. Communication to both inform the Strategy and its translation for local delivery is crucial. Having key messages that inform all policy decisions would also strengthen the cohesiveness across the delivery of the Strategy.

The Regional Strategy should frame health and well being actions as specific social actions with the emphasis on equality of education, training and opportunity with a performance framework which explicitly links social measures and health

It needs to be acknowledged that delivering change through the Strategy is long term and generational. A focus is needed on what can be done in the short term without affecting the medium and long term

There is a challenge on how to counter balance a reduction in public investment – how to get more for less.

Issues: •

Worklessness: there is a need to identify what it is that NHS can do to support people and patients full participation in the social environment. There are opportunities for health services to make a positive contribution to the worklessness agenda and these expectations need to be made explicit.

Communities and social cohesion: local voices must be listened to, with equal value being placed on those that engage and those that don’t. There may be an argument for revisiting community development principles with recognition of the scale of the task and time needed to provide a firm bridge. The unpicking of work achieved is easy but putting it back together difficult. An example would be the care economy where economic growth has been counter balanced by a decline in the care economy and this now needs to be re-built through by local communities.

The regional food offer is a prime example of an issue that runs throughout the Principles and Issues paper and would demonstrate connectivity across the Strategy and across the economic, environmental and social / health pillars of sustainable development.

Public sector procurement of goods and services could be a major tool for integrated actions supporting the regional offer and there are opportunities to be more innovative with examples from other EU countries.

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Older people should be valued as a resource and the view that older people are a burden challenged. Action is needed to ensure an adequate income in older age

Transport networks are poor in some parts of the region e.g. Lancashire and there are also issues of access and affordability. The focus of the Principles and Issues paper is on commuting rather than travel within local areas and developing natural community networks. This is a major issue which makes a significant impact on social inclusion, social cohesion and quality of life.

Planning system: there are significant opportunities through the planning system which need to be maximised to create a health dividend to create “healthy urban and rural planning”.

Healthy workplaces: the private and independent sectors should be incentivised to progress healthy workplaces and those companies that take up the challenge given more recognition.

Income inequalities: the actions in the Strategy should demonstrate how they will contribute to achieving a reduction in the income gap and ensure a living wage for the region’s population.

Further research is needed to demonstrate the relationship between health, economic development and sustainable development to question what the benefits of “growth” are.

Strategic Development •

The Regional Strategy needs to set a clear direction for addressing social determinants and to empower communities and non health partners to commission and deliver interventions to improve health. A governance structure is required that ensures that actions in the Regional Strategy are taken forward and which ensures accountability for delivery which would support local influences on social determinants.

There are a number of points to note regarding measurement of change from the delivery of the Strategy:

There should be outcome measures for health and well being and health inequalities (drawn from national Health Inequalities Review) and targets for reducing health inequalities.

Measurement of positive outcomes should be included rather than the currently widely used measures of place through deprivation.

There needs to be measures that demonstrate joined up working and quality of life, with a measure for every challenge

Monitoring of delivery of the Strategy will need to be scrutinised to make sure not increasing inequalities [Feedback to conference: Appendix 3] 27


Sir Michael and Simon Crawshaw’s summary of the key themes emerging from the feedback to conference Sir Michael Marmot The importance of values: This was expressed in variety of ways, including questioning whether economic growth is the be all and end all. Also the balance between work and family, which is absolutely key. Barriers were another theme. Even before the economic crisis the focus has been on economic growth, the economic miracle, with very little discussion about the nature of the society we want. In a way the economic crisis is the right time to be having that discussion. Issue of inequalities in income is not a simple arithmetic relationship between the magnitude of income and inequalities impacting on health outcomes. Rather the magnitude of income inequality is telling us something about the nature of our society, about how people are valued. Not necessarily income inequality per say, it’s the characteristics where there is no value or equal valuing of people. For example if Bill Gates moved into Liverpool the magnitude of income inequality would go up but it would not affect health inequalities. It’s not that simple. Measurement relates to values and what is it we want to achieve and so what we measure. We use life expectancy as a useful shorthand and as a way of capturing attention not because life expectancy is the only measure. A paper is being done on measures of well being. The process really matters. It’s not just where we want to get to but how we get there, which means inclusion, collaboration and involvement. If there is integration in policy making and an integrated approach, it is then possible to work out the best way to get there which might be through sectors and their contribution. Where is the individual responsibility in this? We want to create the conditions for individuals to take control of their own lives. If you live in a neighbourhood where you can’t buy fresh fruit then you can’t be empowered to take eat fresh fruit. We know that the density of fast food outlets is higher in areas of deprivation and an effect of the economic down turn has been for an increase in fast food outlets. Creating the conditions where individuals can take responsibility is what we should be doing. Regional and local processes and delivery is so important and we want to learn from your experience about where you see the barriers. There is surprisingly little understanding at national level of what’s happening locally and a complete failure of understanding that health is integral to all sectors 28


Simon Crawshaw There are a number of patterns emerging from the discussions. Quality food is a golden example where we can really make a difference in the Strategy, building on what is already being done in region. What if we make the region self sufficient in food? This would help rural communities; protect the landscape; reduce our carbon footprint; sell more quality local produce in local communities. This is the sort of example we are looking at for the Strategy. The Strategy is about economic development and we need to articulate what success looks like. Economic development is important and we need to look at both how we generate wealth and what do we do with the wealth that is generated? What will the measure of success be? How to measure aspirations, self esteem? A better measure might be health outcomes? We are looking long term, this is a twenty year time frame. Those things which have created success where just visible twenty years ago, for example Microsoft – computers, these were emergent industries. This is an effective time scale which gives the opportunity to say what is the potential for this region, what can we do, what makes us different as a region, what we can champion and what will provide a competitive advantage and generate the outcomes we want? A lunchtime meeting took place between Professor Marmot, Mike Farrar Chief Executive of NHS North West and Simon Noakes, Executive Director of Policy and Planning , Northwest Regional Development Agency, to explore the possibility of the Strategic Review of Health Inequalities in England (Marmot Review) forming a collaboration with the North West Region. The purpose would be to develop regional and local delivery mechanisms to support implementation of the recommendations of the national report. An interim report is due shortly and the full report is expected in December 2009. The next steps are for the North West region to establish the details and process for coordinating the content of the collaborative work across the respective organisations. This opportunity for the North West to work with the national review is welcomed by both the NHS North West and the Northwest Regional Development Agency.

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Investing4Health: Maria Duggan: North West Investment4Health Advisor Maria opened with a story: The work we have to do in the region to make sure we are doing the right thing to secure the health and well being of the region. There has been a recent study trip to St Joseph’s, Missouri, to see what is happening there to invest in the health of the local population. St Joseph’s is a decaying post industrial town, destroyed inner city, empty mall. The population cannot support the out of town shopping centre, there is deep poverty, big health inequalities and very poor outcomes especially for the poorest. There is one hospital provider, who asked what are we going to do about the all the avoidable chronic disease which washes up at our doors, and that as a not for profit organisation we have to treat, where there is no health insurance and no social protections. Ten years ago they sat together with their partners in St Joseph and said what are we going to do, how do we do the right thing? What emerged was a pragmatic, partnership driven approach, which is horizontally accountable, it is dynamic, is effective in reducing health inequalities and tackling some areas of profound health need. It is based on achieving a consensus on what doing the right thing needs and recognising that sometimes doing the right thing is a contested issue. This remarkable experience enabled reflection that somewhere in our system with our top down targeted driven, fragmented programme driven approaches, with our organisational silos which despite all our partnership working over last ten years and vertical integration, we simply haven’t achieved an energy in the system that can achieve the kind of relational, intimate, engaged, passionate, socially committed focus from multiple actors which will enable us “to do the right thing” to enable us to improve population health and well being. This is where the regional framework may be helpful about enabling different conversations about doing the right thing. This presentation will say a little about what investment4health is, attempt to define it, make the case for why it is important and locate it in the particular and pressing context of now, say a little bit about work we have done so far and where we want to go and leave you with some questions and dilemmas. Starting with the definitional issue. It’s simple. It can be described as “simple hard” rather than “complicated easy”. It’s a process, a framework, it’s got legs, it’s been promoted by the WHO, it’s in place in many areas in Europe and the rest of the world. It “aims to ensure that 30


those who spend public money on behalf of communities obtain much more value, measured in improved health outcomes and a narrowing of health inequalities”. So it’s a social justice aim backed by rigorous process and evaluation of impacts. It involves a different way of thinking about what constitutes value as well as working with a broad definition of health. It also challenges and extends current notions of efficiency (prevalent literature particularly focuses on local government needs to achieve efficiencies) but we are less clear about what we are going to do with all the money released through efficiencies. Investment4health adds to this as we want to achieve something different from efficiencies, part of the investment4health approach also draws on developing an evidence base and a validated set of methods and tools. Investment4health has a vision, an emerging vision. It’s dynamic, not set in stone, but if we were to achieve and embed the investment4health programme in the region we would have three key dimensions: •

All regional policy and decision makers would be building on the strengths of local communities and political, economic, social, technical and environmental assets, to sustain the region’s health and wellbeing. Effectively this is an assets based approach not just addressing deficit. That public investment decisions would explicitly aim to have a positive impact on the living and working conditions of the population and to reduce harm. In that context and reflecting on Sir Michaels’ previous comments and last year’s Foresight Report, that it’s society itself that is obesogenic and as a public health movement we have to deal with anti-health forces so that we are mitigating harm as well as creating positive health It is strongly focused on leadership so that the Region’s leaders have committed to policies that give equal priority to supporting the health and wellbeing of the population and to sustainable economic growth. We can debate about the difference between growth at all costs and sustainable growth that creates health and well being

Why is Investment4health important? • Health is created, maintained and destroyed where people live, work, educated and play. o The responsibility for creating health is far broader than the NHS, it is not the sole responsibility of the NHS and not reducible to healthcare. o There is a growing body of evidence that shows that health and economic goals are mutually reinforcing21 . o Population health status is a key determinant of local and regional economic capacity. o Improved health enables full engagement with paid employment.

21

Suhrcke, M. McKee, M, Sauto Arce, R., Tsolova, S & Mortensen, J . 2005. “The contribution of health to the economy of the EU”. Luxembourg. Office for Official Publications of the European Communities.

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o

o

Good population health affects local indicators of “human capital”. It is the well educated populations that contribute more to the labour market. An example being Ireland’s maintenance of investment in the education of young people so that when it emerged from 1980’s recession, it recovered quickly because of their long term investment in young people as a major asset. Poor relative population health also increases costs at all levels to local, regional and national economy through the avoidable costs of care.

Health inequalities is an increasing and persistent global phenomenon o Levels of health among the worst off in the UK mirror those in much poorer countries22 telling us that productivity and GDP is not a sole determinant of overall population health.

Health inequalities cause huge, multilayered costs to society o Recent EU analysis shows that inequalities related losses to health contribute 15% of the costs of social security systems and 20% of the costs of health care systems across Europe as a whole 23 so there are massive financial costs and costs to feel of society we live in. Social costs of inequality affect everyone as shown by the rates of mental illness being 5 times higher across whole population in more unequal societies24.

Here in the North West we know some of the data. Life expectancy is generally improving but the rate of improvement lags behind other regions and for both men and women remains significantly lower than the England average. There are big health inequalities not only in spearhead areas. This is one of the challenges to policy makers that we focus on specific geographies but we haven’t yet got very smart at addressing the fact that the poor people don’t always live together. There are substantial pockets of deprivation in wealthy areas and with targeted spatial programmes we are failing to address those. In several districts these gaps are widening and we don’t routinely analyse health inequalities data. Why develop an Investment4health framework now? • There is evidence that the current approaches are not working. As both Sir Michael and the global Report show, the fragmented programmes are not addressing the overall gradient in health. And further, that programmes targeted on individuals and specific communities not producing any sustainable impact. • The recession intensifies the importance of ensuring maximum health value from public investment and reducing harm. There is a moral as well as a practical urgency

22

Marmot, et al 2008, Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet November 8.

23

Machenbach, J.P., Meerding, W.J., Anton,A.E.2007.Economic implications of health inequalities in the European Union. Kunst Erasmus MC – Department of Health, Rotterdam 24

Wilkinson R & Pickett K 2009. The Spirit Level. Why More Equal Societies Almost Always Do Better. Allen Lane.

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that every pound of the public’s money spent on their behalf releases maximum health and well being impact. There is the opportunity of the Integrated Regional Strategy which enables the conditions for improving the population’s health by a broad focus on integrating policy areas across key issues such as housing, transport, employment. When thinking about what doing the right thing might be like, it is to respond to the Integrated Regional Strategy.

What has happened so far? There is a lot already happening across the region, and Investment4health needs to build on these examples of Investment4health type actions in the region. • “Counting Cumbria” is an initiative which captured the public spend in Cumbria and began to look at re-alignment of investment portfolios to meet community needs. • The Liverpool Health Commission concluded that whilst there has been impressive regeneration, inequalities still exist. • The Greater Manchester Health Commission, of which more later. • The Community Cohesion Report from NHS North West which asks ten challenging questions about whether the NHS is grasping all opportunities for community cohesion, facilitating growth and dialogue, and in procuring buildings and services. • Elevate East Lancashire is an example of joint action and investment in health and housing • The Quality Streets initiative. Groundwork and other social enterprises are active in the North West. This initiative focused on measuring the quality of life and challenging our notions of economic productivity and what might constitute success, looking at other measures other than gross value added. • The Social Value work undertaken by NHS North West with PCTs and Trusts to release more public value from NHS spending. However, with all that happening, there is still the same problem of pockets of good practice but overall there is fragmentation and lack of a systematic approach to merging the health and economic agendas. So the critical importance of the discussions at this conference, in the context of the impending Regional Strategy, is that we can, by setting high level principles about the way health should be addressed, start to bring these principles together at the regional level. But there is a long way to go from setting the framework and putting that to action at the level where it will begin to make the difference on the ground. What Next? In conversation with the steering group, Department of Health colleagues and others, the development of the investment4health framework will continue, as a key part of building the social dimension of the Integrated Regional Strategy. That is the aim. What it will look like is the translation of the vision into a practical framework and tools to bring alignment these agendas.

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It will be: •

• •

A checklist of key questions, some criteria to guide investment decisions and provide a common language across policy makers and agencies responsible for the social determinants in the region Summaries of the evidence base to support local and regional case making. Stories and case studies of investment4health thinking and action to exemplify and make sense of the high level framework, recognising the power of the narrative. Setting out approaches to measure progress and impact including some evaluation criteria.

That’s what it will look like – a toolkit. We hope that it will develop better conversations at local and regional level between decision makers and communities. It is how you sit down together in different kinds of relationships. How do we do the right thing? How can we use this framework and toolkit to guide and re-align our investment decisions? And critically, how do we do that through different kinds of conversations with local people, setting local priorities and then look at the money and bend it to achieve better health outcomes? It’s as simple and as hard as that. There are plans for local and region-wide engagement events, with key decision makers in all sectors and communities, to help shape the work and provide the high level framework and indicators in it. This needs to be part of a different developing relationship between local and sub regional agencies and the regional tier. Primarily we want to promote a cultural change and critical to that is winning hearts and minds among leaders.

What are the dilemmas? In health policy, we act as if it is easy to achieve improvement through setting out goals and trajectories to achieve them and measuring progress against them but such an approach obscures the complexity. This work is emergent, it’s a relational process. • • • • •

How can we lever local commitment to participate in a region wide approach? How can we be prepared to “grow” tools and frameworks interactively so they are relevant and used? How can we be committed to such emerging work in the face of programme and target pressures? How can we suspend organisational agendas to develop horizontal accountabilities? How can we do all this quickly enough to meet the challenges?

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North West Health Commissions John Schultz: Chief Executive Stockport Local Authority, lead advisor, Greater Manchester Health Commission, AGMA lead Chief Executive for Health John’s presentation gave an overview of work of the Greater Manchester Health Commission, which could equally have been given by Mike Burrows, Chief Executive of Salford PCT and joint lead advisor to the Health Commission, a commission which is all about working horizontally with and across local authorities, the NHS, academic bodies and the 3rd sector. We are familiar with the current position of life expectancy in Greater Manchester. There is only one district which troubles the national average, the rest are below. The question is why does the Greater Manchester general public put up with this appalling gap in life expectancy between Greater Manchester and national average. This position provides the whole justification for having a Greater Manchester Health Commission. In Stockport borough there is a 10 year plus gap in life expectancy between the ward with the highest life expectancy and the ward with the lowest life expectancy. It’s not just about the gap between Greater Manchester and England, it’s about the difference between districts in Greater Manchester but it’s also about inequalities within different districts. We know the relative contribution of causes of premature deaths that contribute to the gap in mortality. In males we see a reduction in the contribution of coronary heart disease, stroke and lung cancer, but the rapidly increasing contribution of digestive disorders associated with alcohol. There is a slightly different pattern for women, with coronary heart disease falling more noticeably but lung cancer remaining relatively static, indicating more work needed to reduce prevalence of smoking. And again a considerable increase in digestive disease and cirrhosis related to alcohol. This all adds up to 5,000 deaths a year (men and women) in Greater Manchester attributed to smoking; more than 6,500 attributed to cancer; for alcohol a higher contribution to reduced life expectancy than the national average; and suicides being consistently above the national average. That’s the backdrop against which the Commission is working. The Audit Commission carried out a review of health inequalities in Greater Manchester May 2006 – across councils and NHS bodies. They found pockets of good practice but fundamentally there was a lack of leadership in jointly addressing health inequalities from all the key agencies.

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“ ...there is no health vision for Greater Manchester and a lack of champions. Concerted and radical action is required to make a difference and reduce the health inequalities gap... there was a lack of ownership in recognising the GM picture and the value of collaborative effort” That was three years ago. The report was welcomed and was the start of something very constructive. One of first things we did was hold a conference across sectors on health inequalities and signed a pledge: “...we commit to re-doubling our efforts to work more closely together and through our individual efforts...”. This was signed by the Manchester Evening News editor as well as a range of high profile organisations. So we had a background of poor health statistics, a failure of city leadership, but good potential shown by the signing of the pledge, the question was; how to go about organising ourselves to make a difference? Part of the rationale for setting up the Association of Greater Manchester PCTs is exemplified by patient flows, which are predominantly within Greater Manchester - it is a system in its own right. This interdependency was one of the reasons the ten councils continued with a voluntary arrangement ( the Association of Greater Manchester Authorities) after the Greater Manchester County Council had been abolished in 1986. Within the last year a new constitution has been adopted to take the notion of city region governance even further. AGMA is now legally a joint committee with a new structure focused on an AGMA Executive Board. Reporting to the Executive Board are seven commissions and health was the first to be set up. This was building on the Greater Manchester strategy (2003) which had a chapter on health and had led to the creation of wider joint working arrangements at official/officer level. The purpose of the Health Commission is to provide visible political leadership, and challenge and encourage partnership working by acting as a source of influence, including seeking the support of the other Greater Manchester commissions in tackling health in Greater Manchester through horizontal working. It is not about taking away organisations decision making powers, it’s about leadership and challenge to local authorities and NHS bodies and to the general public, for example through the smoking manifesto. The Health Commission’s priorities are to respond to the major killers and the wider social determinants which impact on life expectancy and health inequalities. Why the focus on health inequalities? The outputs from the Health Commission in the last 18 months include: •

AGMA Tobacco Control Manifesto: challenging to local councils through their licensing function, to use planning powers to lean on retail outlets not to put cigarettes by the check outs. 36


• • •

Contributing to the Greater Manchester Multi Area Agreement which has a significant health component on worklessness. Actions to reduce fuel poverty Reducing illicit tobacco: the forces of law and order had no idea that approx 25% of all cigarettes smoked in Greater Manchester are counterfeit or illegal tobacco. Beginning work on alcohol which will require a different approach to tobacco, initially focusing on the positive and negative economic consequences of alcohol use and misuse.

Significant progress has also been made by the Directors of Public Health, who now produce a Public Health Annual Report and Annual Prospectus across Greater Manchester. They are absolutely key to what the Health Commission has achieved. The Health Commission has given them a platform to influence Non Executives and senior counsellors and they have seized that opportunity. The Audit Commission’s follow up report in October 2008 commented positively on the progress made, “this is a remarkable achievement in short space of time”. The one qualification is that mental health not an area of progress which put a focus on this. Work in progress, a number of outputs, too early to talk about outcomes, not complacent but impressive how well the Non Executives and councillors have taken to the health issue, and if continue at level we have so far, improvements will be achieved.

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Steve Maddox: Chief Executive Wirral The Merseyside aspect of health and wellbeing, which whilst not as well developed as Greater Manchester, does have many initiatives which I’m not going to talk about now, as a number of people in audience are from Merseyside and familiar with them. The Directors of Public Health work together and have an organisation called the CHaMPs25 Network. But I want to focus on a couple of themes. I started taking an interest in this issue some ten years ago when there was an initiative in Merseyside and across the country, called Health Action Zones, which reflects the Greater Manchester Health Commission, as it had regular meetings of PCTs, or health authority chairs as they were then and local authority leaders. In the early days, the local authority leaders perhaps did not recognise the role that they had to contribute to health. It shows the change that has occurred over the last ten years, and how if this is the case, and if we call ourselves community leaders, what is it we are doing to address the fundamental health inequalities, which leads to this shame in the larger conurbations of this inequalities gap on life expectancy. In Stockport its ten years, in Wirral its eleven and a half years and even within two miles can produce gaps of ten years. The key theme is finding a way to make sure that the collective resource that we have available to us is deployed to maximum effect, that is the nub of the question. How can you who work in the NHS make best use of say environment health officers, to develop and train the community of fish and chip shop owners to use more healthy ingredients in their food and they are willing to do it? How can you best use development officers to make best use of parks and green spaces? How can you use collective resources to have a healthier impact? How can you use the resource of Wirral council’s £500 million expenditure each year to make sure that the decisions it takes will have a healthier impact. And conversely how can the local authority influence the PCT decisions on expenditure, which, in my view, in the NHS, until recently, have not been sufficiently focused on the issues of prevention as opposed to the cure, and still aren’t. So we have this massive collective resource and also have fantastic collaboration, with officers of local authorities, PCTs and hospitals all working on initiatives, wishing that what they are doing was recognised. What has been missing is this issue of strategic leadership. This issue has been addressed quite well at very local levels through joint working with PCTs and local authorities, joint plans, Joint Strategic Needs Assessment, and is all harmonised. Sub regionally, it is a bit more difficult, AGMA excepted, and perhaps less conjoined. At regional level what binds together the NHS and local strategic partnerships. It’s finding some way to do this. We probably know the answers but need to step back and think about it.

25

CHaMPs – Cheshire and Merseyside Public Health Network

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Enormous progress has been made in terms of our integration. It’s probably a thing of the past the definition of partnership was when we all came together and suppressed our mutual hatred and mistrust of each other, spent someone else’s money. We need to go much further with integration and ultimately, as we all know, the social determinants of health are the issues we need to address in order to solve this problem in the longer term. Ultimately that means giving people aspirations, hope and jobs. It means addressing what happens in school. It means giving people good role models. The key question is, at all these different levels, are you convinced that you are successful in working as collaboratively as you possibly can with partners in local authorities, in order to make sure that what they do isn’t negating what you’re seeking to do and is it complimentary in some way. And to the extent it is not, it requires us to do something about it.

Question & Answer Q: This has been an inspiring event, and I wish you every success. When will the toolkit be ready? A. Maria Duggan The high level aspects of the framework will be set out in our response to Principles and Issues paper for the Regional Strategy and the toolkit will hopefully be ready in the autumn 2009. Q: Equal priority needs to be given to health and economy. It is a very complex formula - how would you measure this? A: Maria Duggan A challenging question as we haven’t got the framework yet. However, there are a range of measures and indicators available to judge the relative priority and economic theories to bring to bear, but we need to ask people in localities that question. What is the value, what is the priority you would place on health and well being for your community, your neighbourhood, and how does that sit relative to standard notions of economic growth? These are the conversations that are needed. We are engaging on a qualitative process of community priority setting. It was very clear from St Josephs that in order to maintain the vibrancy and productivity and halt the drain of the town, they needed to improve population health, and to improve population health had to have money devoted to it and to do this meant diverting money and raise more money from the people who had more money. Those are the kinds of conversations we need to have as how to get more from public sector pound Q: Dr Ruth Hussey Looking across the region, we hear the story of Greater Manchester, hugely impressive at the way systems have come together, but we are still facing some of the worst challenges such as Blackpool and Liverpool. The question is how do we support the region to have the benefit? What would your advice be looking at the Regional Strategy, how could we secure the benefits that you’re seeing in different 39


parts of the sub region for the seventeen million people in the North West? What else would you like to see happen to get everyone have the benefits?

Steve Maddox: We need to look at whose radar is this agenda on? It’s not necessarily about more money. There is some reluctance to make too much development as might create too much noise? It requires strategic leadership for example through planning. It is important not to make it too complicated.

John Schultz: I don’t believe the answer lies in a strategy, though I’m not saying that a strategy has nothing to offer or add but in Greater Manchester we have so much ground to make up that anything we do would be worthwhile. Some of the most valuable things that can happen and are beginning to happen are sharing of good practice. There is huge scope for those areas making progress and those that are not having the will to adopt practice from others rather than signing up to another strategy.

Q: Investment plans are still going head even in recession. How do you see economic investments positively impacting on health inequalities? Steve Maddox: There is something about being aspirational when responding to people who say “well this is not going to happen” and practically using economic purchasing power if you have the will to do things that will have a positive impact. How you design, what jobs, what housing, quality, the importance of where people live are all questions of determination. It’s how to encourage people to want to change and adopt different approaches. Part of what we can do is set the climate, the environment and set aspirations that it doesn’t always have to be like this. John Schultz We have heard a lot of comments about getting the balance right between health and economic but we mustn’t lose sight of the fact that unemployment is positively correlated with ill health. I will oppose unsustainable economic growth but am in favour of sustainable economic growth positive for health. Maria Duggan The Investment4health framework is almost like a campaign. It’s a process of culture change, akin to health impact assessment and critically it is a human process as a well as a technical process. There is some urgency.

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Plenary: Dr Ruth Hussey: There has been a richness of views about what we need to take forward as a population of seventeen million people in the North West. We need to be clear about we are trying to create. What will success look like here, what will it feel like in this region if we have achieved the goals of social justice and tackled social inequality as a driver for health and well being? Something to take away from the day is that sense of shared values, what is the vision, how would we know if we are all doing the same things, how are we learning from each other – as much about process as goals of social inequality? Looking at how we will be work forward with the national review, we have had some conversations about the North West as an exemplar region, to test out some of the approaches. The North West will be the test bed in collaboration with the national review team. The Strategy alone is not enough, delivery plans alone are not enough. If it’s not in our mindset and a passion it won’t happen. Today is the start of the journey, to grab hold of the work that’s emerging globally and nationally that we can apply consistently and coherently in the North West, to be the region that does aspire to bring health and well being to everyone. Professor Sir Michael Marmot: Something has been on my mind all day. For a number of years I have been personally motivated, both intellectually and conceptually, on the topic of health inequalities - conceptually wanting to do something about reducing health inequalities. The main driver was greater understanding. What we seem to have tapped into is a vein of enthusiasm, passion, well meaning, motivated by the highest values to try and improve health and well being for everyone in an equitable way. I have spent my life amassing evidence and am still committed to having the evidence. If there is a possibility of making a difference in a region it’s here manifest in the North West. I look forward to the partnership. Let’s get practical, let’s review evidence globally and nationally and let’s use the North West to really make a difference, working with communities on the ground. I look forward to this region being a pace setter for what we are trying to achieve. Next Steps • To influence and co-produce the Regional Strategy to include measurable actions on the social determinants of health and the improvement of health and well being across the North West.

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• •

• • •

To work with the national review team to be the regional test bed for the recommendations from the review. Through the Investment4health conversations, strengthen community involvement to shape the vision and mobilise engagement to “do the right thing”. To ensure alignment between the Regional Strategy, Investment4health, NHS North West’s Social Value work and sub regional planning and delivery systems including Health Commissions and the sub regional Improvement and Efficiency Partnerships. Provide integrated strategic leadership for improved health and well being for the region. Following the conference, a summary of delegates’ comments have been fed into the consultation for Regional Strategy Arrangements have been made to meet with Michael Marmot’s review team at the end of June.

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Appendices Appendix 1: Delegates Carole Waqar Paul Marie Danila Evelyn Bernadette John Angela Jackie Steve Angela Edna Rob Tony Anne Claire Richard Maggie John Julie David Gary

Adebayo Abbasi Amann Armitage Armstrong Asante-Mensah Ashcroft Ashworth Aspinall Bailey Barwick Beagrie Boampong Bolton Boyle Brenchley Brough Caulfield Chadwick Clucas Collins Conrad Cook

Jane Debbie Brunhilde Mike Katie

Corbett Critchley Corbishley Deakin Dee

Nathalie Dawn Mary David Denise Jane Bill Dr. Paula Francesca

Depledge Edge Farrell Fletcher Francis Friend Gormley Grey Gudger

Liverpool PCT Help the Aged Liverpool City Council NHS WIRRAL DH North West Northwest Regional Development Agency Age Concern Tameside Dr Foster Intelligence Healthy Youth Pennine Care NHS FT 4NW Stockport Metropolitan Borough Council GMPHN Swanswell Liverpool Primary Care Trust Natural England MC2 VSNW NHS Cumbria Liverpool City Council Creative Possibilities NHS Sefton Stockport NHS Foundation Trust Liverpool City Council, committee services Govt Office NW Warrington Disability Partnership NHS North West NHS North West Greater Manchester Public health network The University of Manchester Knowsley Public Health Team AGMA Trafford Housing Trust Groundwork Northwest North Lancs Health Liverpool Primary Care Trust Trafford Housing Trust 43


Dominic Ian Katy Sue Alan Mike Carol Jan Kim Robert Fiona

Harrison Harrison Harrison Henry Higgins Hogan Holt James Johnson Johnstone Johnstone

Hasan Julie Stephen David Wendy Hayley Marion Michelle Jenny Davina Alison Claire David Alison Ian Gill Liza Gulab Laki Emma Paul Martin Yeemay Julia David Angela Maureen Chris Jim Martine Joe Phil

Kazi Kennedy Kingsnorth Lamb Meredith Montgomery Murphy O'Neill Osborne Parr Petrie-Brown Pleasance Regan Ricketts Riding Sadler Scanlon Singh Singh Squibb Stanners Stevenson Sung Taylor Thomas Towers Williams Williamson Wilson Winder Woodford Woods

Jon Yasmin

Workman Zalzala

Department of Health NW Liverpool PCT The University of Manchester NHS North West Oldham Liverpool PCT Royal Liverpool Hospital NWOPAG/SPOC Liverpool City Council ACCESS MATTERS NHS Halton & St Helens Warrington Ethnic Communities Association N. Lancashire Teaching PCT Warrington Borough Ministry NHS Salford NHS Western Cheshire RMBC Merseyside Society for Deaf People NHS North West Manchester City Council NHS Central Lancashire Liverpool Healthy Cities Knowsley PCT Manchester City Council DH NorthWest NHS Ashton Leigh and Wigan NHS North West Salford PCT NHS Central Lancashire Halton Borough Council Liverpool Charity and Voluntary Services Harvest Housing Group Harvest Housing Group Halton BC Liverpool PCT Black Health Agency Food Standards Agency MDF NHS Knowsley NHS Halton & St Helens PCT Lancashire Economic Partnership nwda Warrington BC Mid Cheshire Hospitals NHS Foundation Trust Business Development Services 44


Appendix 2: Speaker Biographies Dr Ruth Hussey, OBE Regional Director of Public Health / Medical Director for NHS North West and DH North West Ruth is the Regional Director of Public Health/Medical Director at NHS North West and leads the Regional Department of Health function which is co-located with other Government Departments in Government Office North West. Her remit includes: • • • •

Health Improvement, Health Inequalities and Health Protection Clinical Leadership Local Area Agreements Ensuring that Social Care is integrated into the Department of Health in the Region

Previously, Ruth held the posts of Director of Health Strategy/Medical Director at Cheshire and Merseyside Strategic Health Authority (April 2002 – July 2006) and between November 2005 and June 2006, Ruth was also the Acting Director of Public Health /Medical Director at Greater Manchester Strategic Health Authority. Prior to this Ruth held the post of Director of Public Health for Liverpool (1991 - 2002).

Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM,FMedSci Director, UCL International Institute for Society and Health MRC Research Professor of Epidemiology and Public Health, University College London Chairman, Commission on Social Determinants of Health Chairman, Department of Health Scientific Reference Group Chairman, WCRF/AICR Food, Nutrition and the Prevention of Cancer report Biographical Details: Michael Marmot has led a research group on health inequalities for the past 30 years. He is Principal Investigator of the Whitehall Studies of British civil servants, investigating explanations for the striking inverse social gradient in morbidity and mortality. He leads the English Longitudinal Study of Ageing (ELSA) and is engaged in several international research efforts on the social determinants of health. He chairs the Department of Health Scientific Reference Group on tackling health inequalities and is an Honorary Fellow of the British Academy. He was a member of the Royal Commission on Environmental Pollution for six years. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities. Internationally acclaimed, Professor Marmot is a Vice President of the Academia Europaea, a Foreign Associate Member of the Institute of Medicine (IOM), and the Chair of the Commission on Social Determinants of Health set up by the World Health Organization in 2005. He won the Balzan Prize for Epidemiology in

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2004, gave the Harveian Oration in October 2006 and won the William B. Graham Prize for Health Services Research in 2008. Research Interests: Marmot's research has been devoted to establishing the chain of disease causation from the social environment, through psychosocial influences, biological pathways, to risk of cardiovascular and other diseases. In studies of Japanese migrants to the USA and migrants to Britain from a number of countries, he showed that disease rates change. The longer the migrant has been in the new country, the more closely rates of disease resemble those of the new country. A specific object of investigation was the high rates of cardiovascular disease and diabetes among immigrants from the Indian subcontinent. This defied the usual explanations. Marmot showed it was related to the metabolic syndrome related to insulin resistance and the resultant lipid disturbances. This same set of biological mechanisms proved important to the inverse social gradient in cardiovascular disease in Britain. Marmot's studies of civil servants showed that the lower the status, the higher was the risk. Plasma fibrinogen and the metabolic syndrome mediate much of this excess risk. Marmot produced evidence linking low control at work to the increased risk of cardiovascular disease. He and his colleagues have good evidence that psychosocial stress pathways are involved in the metabolic disturbances observed. It is these pathways that provide the most promising explanation for the new phenomenon that they are investigating: the dramatic increase in cardiovascular disease and drop in life expectancy that occurred in Russia and other former communist countries of Central and Eastern Europe. A new thrust of the research is its application to an ageing population. Professor Marmot teaches on the new MSc Health and Society: Social Epidemiology course. Tracy Mawson Head of Regional Strategy, Northwest Regional Development Agency Tracy Mawson joined the Northwest Regional Development Agency as Head of Economic Strategy in September 2007, having previously worked in economic development in Liverpool City Region. Tracy is Head of Regional Strategy at NWDA, with responsibility for development of the NW2010 single Regional Strategy and Regional Economic Strategy 2006 implementation and monitoring. Tracy works within the Policy and Partnerships Directorate of NWDA. Tracy’s experience in economic development, regeneration and sector / enterprise growth in Liverpool City Region, supported by her MBA in Urban Regeneration and prior degree in Economics, supports her work assisting the Northwest in developing an holistic and integrated path to Sustainable Economic Growth. Before moving to Liverpool in 2003, Tracy worked in London in management consultancy and e-business. Maria Duggan PhD Maria is a consultant adviser to the North West Regional Public Health Team, supporting current work to develop an Investment for Health Framework for the Region. Maria has an academic background as a sociologist. In a lengthy career she has been a social work practitioner, a director of social services, an academic in the field of social and health policy, an associate of the Kings Fund and the Nuffield Centre for Health and the 46


Institute for Public Policy Research. Maria was the Director of Policy at the Association for Public Health until 2004. Maria has an extensive portfolio as an independent, health and social care policy analyst, organisational development consultant and researcher working on commissioned projects for the Department of Health in England, numerous national, regional and local government agencies in England and a range of international and national academic and research institutes and both statutory and independent health bodies and agencies Stephen Maddox Chief Executive, Wirral Council Steve was born in Merseyside in 1953. He attended Merchant Taylors’ School in Crosby and graduated from the University of Kent in 1974 and joined Wirral Council in December 1974 as a Trainee Solicitor, qualifying in 1977 and became the Council’s Deputy Borough Solicitor and Secretary in 1991 He was appointed Chief Executive of Wirral Council in March 1998. He is Clerk to Merseyside Passenger Transport Authority, a Board Member of Greater Merseyside Connexions Partnership and a Governor of Wirral Metropolitan College and Black Horse Hill Junior School. He has a longstanding interest in Public Health and cochaired the Merseyside Health Action Zone. He currently co-chairs the Cheshire and Merseyside Public Health Network. He was awarded an OBE for Services to Local Government in the New Years Honours List 2007. He is married with two sons, (one Evertonian, one Liverpudlian) enjoys motorcycling and cooking. John Schultz John Schultz was President of SOLACE (the Society of Local Authority Chief Executives and Senior Managers) in 2006/07. He has been Chief Executive of Stockport Metropolitan Borough Council since 1994. He previously worked for county and district councils, in both metropolitan and shire areas, and has served as advisor to various central government departments and regional bodies. He is the joint author of a book on local government management. He holds a geography degree from the University of Oxford, and a postgraduate planning qualification from the University of Manchester. He is married to a special needs teacher, and they have two adult daughters.

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Appendix 3: Feedback to Conference Question 1: What would you wish to see in the national report that would assist you in delivering a reduction in health inequalities? Table 2 • The National Strategy should focus on health measures and positive health rather than mortality • NW keen to work on progressive universalism idea particularly children and young people – working with the gradient Table 3 • We (sectors, public, private and government) have a common agenda to improve health and well being – a collaborative approach from national to local • We need indicators that measure the collaborative contribution Table 4 • Where does personalisation (taking personal responsibility) fit with reducing health inequalities • The delivery of the National Report needs to clarify roles and responsibilities at central regional and local tiers. Define what remit and power local organisations have to influence wider social determinants. Table 5 • The National Report to clarify the contribution that different agencies make to health inequalities beyond the bio medical model: to compel government to set measurable targets for agencies that captures their specific contribution and responsibility for delivery. Table 6 • We feel that the national report needs programme delivery that provides bridging for social capital and enabling people from different groups to appreciate each other. Table 7 • Accept that reducing health inequalities is the right thing to do – but it would be useful to be able to quantify the positive and negative impact on the economy so that we can look at opportunity costs. • What is the something else, over and above reducing income inequalities that we should do particularly as income can’t explain all the differences? Table 8 • There needs to be an emphasis on healthy life expectancy • The national plan needs to address the resource question

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Table 9 • Wants the emphasis to be put on the evidence to practice and on what it would look like at local level to have a social determinants approach as the dominant approach to health equity Table 10 • Considering it’s a conversation we have been having for years – what are the barriers – do we know as these will need to be tackled in the delivery plan(s). • More value put on carers and their contribution – more value on community contribution that’s not measured Table 11 •

Reducing the gap in income inequality

Community – wider appreciation of the public value: quality of life v GDP per head of population

Go for 100% (universal services)

Table 12 • Although good progress being made on long term conditions, the benefit system needs to be made more enabling, less punitive with more value placed on carer’s contribution. • More R & D is needed to analyse the relationship between health, economic development and sustainable development to identify the benefits of growth. Question 2: What are the key health and well being actions that you wish you see in the North West Integrated Regional Strategy Table 2 • Health and social inclusion should be more explicit throughout the document • How can we make integrated working happen on the ground – good in theory but lots of barriers Table 3 • A strategy that truly contains actions that reflect the needs of our communities. In a language that all can understand. • The governance structure that ensures the actions of the IRS are taken forward Table 4 •

Define and broaden aspiration aspect: what do individuals and communities aspire to? What do businesses aspire to (need to consider CSR as well as profits), how can the strategy influence aspirations of individuals and communities?

Table 5

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The Regional Strategy needs to set a clear direction for addressing the social determinants and to empower communities and non health partners to commission and deliver interventions to improve health

Table 6 •

What are we aiming for? GDP or (broad) quality of life (i.e. social capital)

Table 7 •

IRS: economic, health and spatial planning : strategies must be integrated together

Tackling worklessness – need to be more explicit about the positive contribution we should expect from health services – levers – e.g. health offer around rehabilitation.

Table 8 •

Give as much attention to the health and well being elements as the economic elements

Address work stresses – healthy workplaces

Table 9 •

We want the Integrated Regional report to give the concept of social justice equal status to economic development (and not be sacrificed to it) and that actions on social determinants are explicitly linked to measures of health equity.

Table 10 •

Translate Michael Marmot’s recommendations into actions: let some initiatives work – give them time. Accept no quick fixes – no big answerable of little ones

Table 11(ref Q1) Table 12 •

Volunteering and action within communities needs to be valued in different economic terms – as social and human capital

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Appendix 4: Glossary What is social capital?26 Social capital describes the pattern and intensity of networks among people and the shared values which arise from those networks. Greater interaction between people generates a greater sense of community spirit. Definitions of social capital vary, but the main aspects include citizenship, 'neighbourliness', social networks and civic participation. The definition used by ONS, taken from the Office for Economic Co-operation and Development (OECD), is "networks together with shared norms, values and understandings that facilitate co-operation within or among groups"1. Why does social capital matter? Research has shown that higher levels of social capital are associated with better health, higher educational achievement, better employment outcomes, and lower crime rates. In other words, those with extensive networks are more likely to be "housed, healthy, hired and happy"2. All of these areas are of concern to both policy-makers and community members alike. The social determinants of health (SDH) are specific mechanisms by which members of different socio-economic groups come to experience varying degrees of health and illness. Across the globe, individuals of different socio-economic status show profoundly different levels of health and incidence of disease and similarly there are national differences in population health. For example USA and Sweden which shows that the organization and distribution of resources among the population has an impact on health and wellbeing.

26

ONS

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http://www.nwda.co.uk/pdf/HEALTH%20INEQUALITIES%20and%20IMPACT%20on%20the%20ECONOMY2  

http://www.nwda.co.uk/pdf/HEALTH%20INEQUALITIES%20and%20IMPACT%20on%20the%20ECONOMY2.pdf