ADD2647 Mayor’s Six Tests and health inequalities evidence review

The Mayor’s six tests
1.1.    The Mayor has committed to championing and challenging the NHS on behalf of Londoners, and this has been identified as a mayoral priority.
1.2.     In 2017, in response to a report commissioned by the Mayor into London’s five Sustainability and Transformation Plans (approved under ADD2067), he announced six ‘tests’ he expected to be met before he gave his support to any major health and care transformation or hospital reconfiguration proposals in London. These tests cover:
•    health and healthcare inequalities 
•    hospital-bed capacity 
•    financial investment and savings 
•    impact on social care 
•    clinical support 
•    patient and public engagement 
1.3    This ADD is seeking approval to procure expert external consultancy services, up to the value of £25,000, to prepare an assessment of NHS proposals to reconfigure children’s cancer services in south London hospitals against the Mayor’s six tests.  
1.4    The following decisions have previously been agreed for expenditure to assess major hospital reconfigurations against the Mayor’s six tests:
•    ADD2408: approval for expenditure of up to £20,000 
•    MD2799: approval for expenditure of up to £60,000
•    ADD2608: approval for expenditure of up to £15,000 
1.5    During 2023-24 we expect the NHS in London to announce further major service reconfiguration proposals, to which we may wish to apply the Mayor’s six tests.  We will seek further approvals for assessments against the Mayor’s six tests once the nature and timing of these proposals is known.
Building the evidence for health inequalities 
1.6     This work programme supports the Mayor’s leadership-for-health role; and comprises activity to support pan-London activity to tackle health inequalities, including through supporting, mobilising and empowering a wider range of partners to act. Further detail on each work programme is provided below.

1.7     This resource is to support the development of the evidence base for health inequalities in London, in the context of London priorities. In 2022 a grant agreement was agreed (£100,000) and signed with University College London’s Institute for Health Equity, led by Professor Sir Michael Marmot, to support their work to develop the evidence for action on health inequalities. The Institute for Health Equity is made up of leading experts in health inequalities, who have done extensive work at city, national and international levels. The “building the evidence for health inequalities” programme supports collaboration with the Institute, whose members were keen to apply their extensive expertise and evidence-based frameworks to London. The Institute is developing a series of evidence reviews, focused on “what works”, to make a difference to health inequalities in London. This work programme links to the partnership work of the London Recovery programme.  This will inform the evidence base for London partnership work on health equalities. 

1.8    The resource for the £100,000 grant agreement was agreed over two decisions – MD2906 (£75,000) and MD3031 (£25,000). Since this time, the work programme has developed and we are now planning to extend the grant agreement and provide a further £20,000 to support work to develop the evidence base around structural racism and health inequalities in London. This review requires a different approach from the others in the series – it has and will continue to involve more collaborative work with partners, and a high level Advisory Group has been established – and it also involves a different approach to evidence gathering and review, and in particular the need to work with and learn from affected communities. 
 

The Mayor’s six tests 

2.1    The overall objective is to provide the Mayor with a systematic, objective and independent 
assessment of an individual major NHS service reconfiguration proposal against his six tests; this 
will help him to determine the extent to which the tests have been met, and to champion and 
challenge the NHS accordingly on behalf of Londoners. 

2.2     For each test, the consultants will highlight positive evidence towards the test being met, as well 
as areas where there is a lack of evidence. They will also critically assess key assumptions on which the hospital reconfiguration proposal is based; and highlight any areas in need of further 
development and/or challenge. 

2.3    This assessment will form part of an overall briefing for the Mayor to inform his response to the proposed service reconfiguration. The assessment will be published on the GLA website 
alongside the Mayor’s response.

Building the evidence for health inequalities

2.4     The objective is to improve the health inequalities evidence base for London – so that the Mayor and stakeholders have a better understanding of what effective action can be taken to address them. This decision relates specifically to the evidence review focussing on structural racism as a determinant of health, and the need to have a better understanding in London of what we can do to make a difference to Londoners lives, and address ethnicity related health inequalities. 
 

3.1    Reducing health inequalities underpins most of the health and wellbeing team’s work, including the Mayor’s six tests. Health inequalities are differences in health that are unnecessary, avoidable, unjust and unfair. They often exist between groups of people with protected characteristics, and who experience poverty and socioeconomic deprivation.
3.2    The assessment against the Mayor’s six tests includes a specific focus on reducing health and healthcare inequalities. The first test  specifically aims to ensure that proposals: make the most of every opportunity to reduce health and healthcare inequalities, and set out an evidenced plan for further action. The assessments will enable the Mayor to champion and challenge the NHS accordingly. 
3.3    This work aligns with the Mayor’s Equality, Diversity, and Inclusion Strategy Objectives (2022). In particular Objective 12, which commits to address the reasons for health inequalities that cause some groups to experience poorer physical and mental health outcomes.  
3.4     The work programme to build the health inequalities evidence base is part of the London Health Inequalities Strategy, and aligns also with the above EDI objective. The specific focus on structural racism as a driver of heath inequalities is a key commitment of the London Health Inequalities Strategy (published in the 2021-24 implementation plan) and also aligns with the Building a Fairer City work programme.   In June 2021, an equalities sub-group of the London Recovery Board was formed to focus on the structural inequalities that caused certain communities to experience disproportionate impacts of the COVID-19 pandemic; and on new inequalities that have arisen because of the crisis. Building a Fairer City, the LRB’s structural inequalities action plan for London, was published in May 2022. Under the priority area of building equity in public services, there is a specific action on tackling structural racism, which the evidence review will directly inform. 
 

Risks and issues 
4.1.    The exact timetable for the number of six tests assessments likely to be needed this year, some of which may need to run concurrently, may present challenges in securing multiple expert providers for delivery.  The work is also dependent on the NHS timetable for publishing public consultations on specific reconfiguration schemes, which is not yet fully known.  In mitigation, officers will undertake market cultivation early in 2023/4 to ensure potential providers are ready to tender for the work when schemes are announced.
Links to Mayoral strategies and priorities
4.2    This work has links to the Mayor’s HIS, which sets out plans to tackle unfair differences in health to make London a healthier, fairer city. Health inequalities are inextricably linked to other types of inequality. This is because they are most often a direct result of inequalities in other areas of life, i.e. socioeconomic differences. The strategy outlines key actions to address the socioeconomic causes of poor health (social determinants). 

4.3    Applying the six tests to a major service reconfiguration will promote the implementation of the HIS; and will contribute towards the ambitions to address London’s stark health inequalities, and to reduce the number of years Londoners live in poor health. 

4.4     There are no conflicts of interest to note for any of the officers involved in the drafting or clearance of this decision form.
Subsidy Control
4.5    Decision 2 of this decision form requests approval for the variation of the GLA’s existing grant agreement with University College London.  The variation will increase the GLA’s existing grant to University College London from £100,000 to £120,000.
4.6    The proposed £20000 extension of the grant to University College London’s (UCL) Institute for Health Equity (IHE), discussed in this Assistant Directors Decision, is a continuation of work that the Mayor of London has previously funded. We have identified a need to provide further resource to ensure that the objectives of the work be achieved. 
4.7    UCL is a leading London based academic institution, and likely receives funding from other public sector organisations, to support core delivery and research. UCL’s IHE undertakes national and international work as part of their renowned programme on health inequalities and wider determinants of health. 
4.8    This grant supports and enables the application of IHE’s unique expertise to the context and challenges in London. Without the provision of this grant from the GLA, this London focussed programme would not have happened.
4.9    This work programme focusses on academic research into health inequalities in Greater London. The benefits of the work include that it will improve understanding of contemporary health inequalities challenges in the city, and effective interventions to mitigate or address them, that can be taken forward in London. We have not identified any negative effects on domestic competition or investment and international trade or investment, related to this grant. Indeed, the work on structural racism and health inequalities may create indirect benefits nationally and internationally, as this is a new, not-previously-funded, area of focus for the IHE. 
 

Approval is sought for the following;

1.    Expenditure of up to £25,000 to procure expert consultancy services to provide an independent assessment of proposals to reconfigure children’s cancer services in south London hospitals against the Mayor’s six tests;
2.    Expenditure of £20,000 grant funding to University College London as an extension to an existing £100,000 grant agreement (approved in MD3031)
5.2    The total expenditure of up to 45,000 above will be funded from the following programme 2023-24 budgets in the Health team; £25,000 from the Mayor’s six tests programme budget, £20,000 from the HIS programme budget.

5.3    There is sufficient budget to fund the total expenditure of up to £45,000 within the Health unit’s budget.
 

Power to undertake the requested decisions
6.1    The foregoing sections of this report indicate that the decisions requested of the assistant director concern the exercise of the Authority’s general powers and fall within the Authority’s statutory power to do such things considered to further or which are facilitative of, conducive or incidental to the promotion of social development within Greater London and in formulating the proposals in respect of which a decision is sought officers have complied with the Authority’s related statutory duties to:

•    pay due regard to the principle that there should be equality of opportunity for all people;

•    consider how the proposals will promote the improvement of health of persons, health inequalities between persons and to contribute towards the achievement of sustainable development in the United Kingdom;

•    consult with appropriate bodies.    

6.2    In taking the decisions requested, the assistant director must have due regard to the Public Sector Equality Duty; namely the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Equality Act 2010, and to advance equality of opportunity between persons who share a relevant protected characteristic (age; disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex; sexual orientation) and persons who do not share it and foster good relations between persons who share a relevant protected characteristic and persons who do not share it (section 149 of the Equality Act 2010). To this end, the director should have particular regard to section 3 (above) of this report.

Procurement
6.3    Decision 1 of this decision form requests approval of budget for the procurement of services.  To that end, the officers are reminded to comply with the requirements of the Contracts and Funding Code when undertaking the procurements.  Furthermore, the officers are reminded to ensure that an appropriate contract be put in place between the Authority and the relevant services provider, before the services commence.
Grant funding
6.4    The proposed variation of the Authority’s existing grant to University College London will increase it from £100,000 to £120,000.  The officers must ensure that the grant be varied in accordance with its terms, before any of the additional funding be provided.
6.3    The Subsidy Control Act 2002 requires that grant funding comply with its subsidy control principles.  The officers have set out at paragraphs 4.5 to 4.9 above how the proposed grant complies with those principles.  Finally, given that the variation will bring the total value of the Authority’s grant above £100,000, the officers are reminded to register the grant on the Department for Business, Energy & Industrial Strategy’s Transparency Database.
 

Mayor’s six tests

Building the evidence