MD2344 London Health Inequalities Strategy

The Mayor is required to prepare and publish a Health Inequalities Strategy (“HIS”) for London, which contains proposals and policies for promoting the reduction of health inequalities between persons living in Greater London. The Greater London Authority Act (“the GLA Act”) defines “health inequalities” as “inequalities in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants”. It requires policies and proposals in the strategy to be addressed to the mitigation of differences in the following “general health determinants”:

• Standards of housing, transport services or public safety;
• Employment prospects, earning capacity and anything else that affects levels of prosperity;
• The degree of access or difficulty with which persons have access to public services, including good quality health care;
• Personal behaviour and lifestyle factors, including tobacco, alcohol use or other substances that may be harmful to health; and
• Anything else that determines health or life expectancy, except for genetic and biological factors.

The GLA Act states that the HIS must:

• Identify any issues that appear to the Mayor to be major health issues where there are health inequalities between persons living in Greater London;
• Identify those inequalities;
• Specify priorities for reducing those inequalities; and
• Describe the role to be performed by any relevant body or person for the purpose of implementing the strategy.

In formulating the HIS, the Mayor must have regard to: any relevant guidance given to him by the Secretary of State about the matters which he is to take into account, the principal purposes of the Authority, the effect that the HIS will have on various cross-cutting themes (health, health inequalities, sustainable development and climate change), as well as on the need to ensure consistency with national policies as the Secretary of State may notify to the Mayor, the UK’s current EU and other international obligations, the resources available for implementation of the strategy, and the desirability of promoting and encouraging the use of the River Thames safely. The HIS must also be consistent with the Mayor’s other strategies. There are, or will be, new versions of all of these strategies, including a new London Plan. An Integrated Impact Assessment (IIA) was undertaken as part of the development of the draft HIS (Appendix C) – this is further described in section 4.2 of this MD.

The statutory Health Advisor and the Mayor must collaborate and co-operate with each other generally for the purposes of the preparation, or any revision, of the HIS, and in particular for the purpose of ascertaining the issues that are to be identified in the HIS as set out in 1.2 above. The Mayor and the statutory Health Advisor collaborated and co-operated regularly throughout the course of the strategy development. Regular meetings were also held between the statutory Health Advisor and Mayoral Director, and the Mayor’s senior health policy advisor.

The London Health Inequalities Strategy:

The vision for the HIS is for London to be a healthier, fairer city, with all Londoners having the best opportunities to live a long life in good health. The HIS sets out five key aims, for the Mayor and partners, to address health inequalities in London over the next decade to 2028, and focuses on the wider determinants of health, the conditions in which people are born, grow, live, work and age. The five key aims for London have been agreed by the London Health Board and the wider health and care strategic partnership, and they build on the ten shared Better Health for London ambitions developed in 2015 .

• Healthy Children: Every London child has a healthy start in life
The key ambition is to ensure the wide adoption of the Healthy Early Years London programme, particularly in the most deprived communities.
• Healthy Minds: All Londoners share in a city with the best mental health in the world
The key ambition is for more Londoners to receive training in mental health first aid informed approaches, starting with young Londoners.
• Healthy Places: All Londoners benefit from an environment and economy that promote good mental and physical health
The key ambition is for London to have the best air quality of any global city, with progress fastest in the most polluted areas, benefitting people most vulnerable to the effects of air pollution
• Healthy Communities: London’s diverse communities are healthy and thriving
The key ambition is to help more Londoners in vulnerable or deprived communities to improve their health and wellbeing through social prescribing.
• Healthy Living: The healthy choice is the easy choice for all Londoners
The key ambition is for all Londoners to be doing the physical activity they need to be doing every day to stay healthy, with efforts focused on supporting the most inactive.

The Mayor is committed to a mental and physical health in all policies approach, which means that the GLA will work towards considering health and health inequalities in everything it does. This includes the development and implementation of statutory and other strategies. The Mayor’s statutory responsibilities for planning, transport, housing, economic development, environment, culture and sport, and policing, provide a range of opportunities to make a difference to many of the wider determinants that affect the health of Londoners. Other Mayoral priorities also have the potential to help reduce health inequalities, including his strategies on food, skills, social integration and equality, diversity and inclusion. In the development of all these strategies, the Mayor has considered how they can have a positive effect on the mental and physical health of different groups of Londoners.

The HIS builds on work already happening in local neighbourhoods, boroughs, and across the city, and a vital part of the Mayor’s role is to work with those organisations and people, support their efforts and lead the way by setting the strategic direction for the whole city. The HIS is a strategy for the whole of London, and its success is dependent on partners – including the NHS, local government, Public Health England and the voluntary and community sector - getting behind the shared aims and objectives, and collaborating to make a difference. The HIS also calls on partners to take the lead on action within their own remits, to address London’s health inequalities, and work alongside the Mayor to implement the strategy.

Strategy development was led by the GLA and Public Health England (PHE) London, in partnership with NHS England, the Office of London Clinical Commissioning Groups (CCGs), London Councils, Association of Directors of Public Health London, Healthy London Partners and representatives of the NHS acute sector.

Consultation Process:

Under MD2143, the Mayor approved Better Health for All Londoners - the draft London Health Inequalities strategy and an Integrated Impact Assessment (IIA) report for public and stakeholder consultation. The draft HIS was published on 23 August 2017. It was available on London.gov.uk for fifteen weeks and the consultation period closed on 30 November 2017. The draft strategy set out the main issues that lead to inequalities in the health of different groups of Londoners, and policies and proposals for reducing them. Alongside the draft strategy, the following associated documents were also published and formed part of the consultation materials.

• An easy read version of the executive summary
• A commissioned Integrated Impact Assessment (IIA)

These were made available on the GLA’s website, and people were signposted to the consultation portal. Respondents were able to submit their response to a series of questions outlined in the draft HIS through an online survey, emails or letters, and drop-in sessions at City Hall. There were also further opportunities for public consultation, including through the Talk London platform – for further information see 1.12 below.

Section 42 of the GLA Act provides that when revising any mayoral strategy, the Mayor must consult the following:

• The Assembly
• The functional bodies
• Each London borough Council
• The Common Council of the City of London
• Voluntary bodies some or all of whose activities benefit the whole or part of Greater London
• Bodies which represent the interests of different racial, ethnic or national groups in Greater London
• Bodies which represent the interests of different religious groups in Greater London
• Bodies which represent the interests of persons carrying on business in Greater London

Section 309G of the GLA Act provides that in preparing or revising the strategy, the Mayor must consult the following bodies set out in section 309E(5) as appear to him to be likely to be affected by the strategy:

• Any London Borough Council
• The Common Council
• The Health Advisor
• The Secretary of State in relation to the exercise of certain statutory functions
• The National Health Service Commissioning Board
• Any clinical commissioning group
• Any NHS trust, whose hospitals, establishments or facilities are situated in Greater London
• Any NHS foundation trust any or all of whose hospitals, establishments or facilities are situated in Greater London
• Any other body or person which appears to the mayor to have responsibilities in relation to Greater London, or any part of Greater London, with respect to any of the matters that are general health determinants.

The consultation process was conducted in accordance with the statutory requirements. By responding to the questions posed, it was hoped that the HIS would be refined and improved. It was further hoped that a full and open consultation process would build engagement with the many partners who have a vital role in addressing London’s health inequalities.

Public Engagement: Public consultation on the draft strategy was managed by the GLA’s Opinion Research and Statistics Team following best practice. This was promoted via dedicated pages on London.gov.uk website and Talk London website, and through social media. Members of the public were invited to join the discussion on Talk London, to attend drop-in events, or to respond to the strategy in writing. Quantitative research was also undertaken with a representative sample of Londoners via a polling provider (YouGov).

Stakeholder engagement: The Health Team managed the stakeholder consultation process. Five priority audiences for stakeholder engagement were identified: London boroughs, education and childcare sector, NHS, voluntary and community sector, and businesses. Stakeholder engagement plans were developed for each audience – details of this can be found in Appendix C. Materials developed to support the consultation included: an online survey; a core slide pack; a list of frequently asked questions; and a technical pack (compiled by Public Health England).

Consultation Response Analysis

Public engagement:

• 2016 responses via The Talk London Survey.
• 1003 individuals participated in a YouGov poll as a representative sample of London adults.
• 18 emails from members of the public writing in to express specific feedback on the strategy.
• 12 responses were received from individuals who attended the drop-in sessions.

This input was reviewed and included as part of the analysis of consultation responses.

A total of 203 responses were received from stakeholders via a variety of channels. A coding framework was developed to enable the GLA Health Team to code and analyse stakeholder responses. Overall there was strong support for actions to tackle health inequalities. Respondents welcomed action on areas such as childhood obesity, social prescribing, HIV, a place based approach to health, and the emphasis on mental health though many responses asked for more detail or for the Mayor to go further. There were also requests for more emphasis on poverty and income inequality as determinants; more detail on how the strategy would be delivered and measured; a greater emphasis on a systems approach as opposed to individual behaviour change; and greater recognition and understanding of the role and work of partners such as London boroughs and the community and voluntary sector.

Final Strategy Text

The preparation of the final HIS has taken into account the comments received from stakeholders and the public through the consultation. In addition, consistency between other strategies has been checked and where appropriate amendments have been made.

Officers produced a Consultation Report to the Mayor which is attached as Appendix B. This contains details of the consultation process, the issues raised by respondents, and officers’ resultant recommendations for changes to the HIS. Should the Mayor wish to see individual responses they can be provided.

Officers recommend a number of amendments to the HIS in response to the issues raised during the consultation, including (and this is not an exhaustive list):

• The addition of new objectives, the amalgamation of others, and amendments to the wording of some objectives
• Renaming of the fifth theme – for healthy habits to healthy Living – and subsequent repositioning of child obesity objective
• Clearer reference to public sector equalities duties and the health in all policies approach
• Stronger narrative on the influence of poverty and income inequality on health inequality
• Further information on partner roles and partnership working, including specific calls for partner action

Related amendments included updated information on GLA (health team and otherwise) strategies, policies and programmes, as well as on the health and care devolution agreement.

Once published, the HIS provides a vision for addressing the stark health inequalities that exist in London, so that no one’s health suffers because of who they are or where they live, and sets a direction of travel for collaborative working over the next ten years to 2028 with partners, agencies and communities.

An initial implementation plan has been produced that sets out priority actions to mobilise the strategy over the next two years. The implementation plan is not part of the formal strategy process.

The plan includes key targets and milestones relating to the five key ambitions and any others which have been agreed. It is a rolling plan, as meeting the objectives of the strategy will require successive and cumulative London-wide activity over the longer term. This plan will be updated annually as the Mayor reflects on what he can do, and as he works with partners across the system to develop new approaches and projects.

Progress in delivering the London Health Inequalities Strategy will be overseen by the London Health Board, chaired by the Mayor. The implementation plan will be monitored and reviewed annually, through the London Prevention Partnership Board.

In addition, the Mayor and partners have agreed fourteen headline population health indicators that will be used to monitor London’s progress in reducing health inequalities over the next ten years. These indicators will track change in the key dimensions of health inequality that the strategy seeks to address, looking at outcomes across London and changes over time.

Under s149 of the Equality Act 2010 (the Equality Act), as a public authority, the GLA must have due regard to the need to eliminate unlawful discrimination, harassment and victimisation, and to advance equality of opportunity and foster good relations between people who share a protected characteristic and those who do not. Protected characteristics under the Equality Act are age, disability, gender re-assignment, pregnancy and maternity, race, religion or belief, sex, sexual orientation, and marriage or civil partnership status (the duty in respect of this last characteristic is to eliminate unlawful discrimination only). Further section 33 (1) of the GLA Act requires the Mayor to make appropriate arrangements with a view to securing that in the formulation of the policies and proposals to be included in any of his statutory strategies, and in their implementation there is “due regard to the principle that there should be equality of opportunity for all people”.

The health inequalities strategy is designed to address systematic and unfair differences in mental and physical health between groups of people. The document details some of the specific inequalities experienced by different groups of Londoners, how their health is affected and how the Mayor proposes to address them within his powers. This includes socioeconomic inequalities, as well as inequalities experienced by those with single or multiple protected characteristics under the Equalities Act 2010. The ambition of the strategy is to improve health for all through an approach of proportionate universalism: universal approaches, with additional support in proportion to need.

In addition to fulfilling this legal duty the Mayor will consider wider issues such as poverty and socio-economic inequality, and the challenges faced by people from other marginalised groups.

An Equalities Impact Assessment in respect of the draft London Health Inequalities Strategy was included in the IIA and assessed its effects on the different equality groups. The Mayor is invited to read and take the information in the IIA into account as part of this decision as to whether or not to approve the final HIS.

The draft London Health Inequalities Strategy was available in a format that was accessible to blind and visually impaired people, and the executive summary was available in an EasyRead format for people with learning disabilities. Deaf and hearing-impaired people could also contact the GLA if they required further information, or were not able to access the internet or email. In addition, people were welcome to provide responses in writing. Requests for the documents to be made available in other formats and translated into other languages were to be considered on a case by case basis, although no such requests were made. These options will be available for the final Strategy.

a) key risks and issues

GLA officers have adopted project management techniques and ensured that any risk has been appropriately identified and mitigated throughout the process of the development of the revision of the strategy. This includes close working with Public Health England to ensure the strategy is informed by the latest available evidence.

b) links to Mayoral strategies and priorities

Section 41 of the GLA Act provides that in revising the strategies, the Mayor shall have regard to the need for each of the mayoral strategies to be consistent with each other. Section 41 also requires the Mayor to have regard to the need to ensure that the transport strategy is consistent with national policies and with such international obligations as the Secretary of State notifies to the Mayor.

Officers have worked to ensure that the statutory obligation and good practice are met in relation to integration and consistency between the Mayor’s statutory strategies. At the date of publication of the HIS (subject to the Mayor’s approval), the Mayor’s Transport Strategy, the London Environment Strategy, and the London Housing Strategy have been adopted (the latter pending review by the Secretary of State). While regard has been had to the issue of consistency with the Mayor’s strategies at present in force, some of these strategies do not address current circumstances. Accordingly, consistency in the HIS has been sought with the current drafts of the other emerging revised strategies and not with the, soon to be superseded, statutory strategies currently in force. Consequently, the HIS has been developed with engagement with the other strategy teams within the GLA.

Impact assessment and consultation

An Integrated Impact Assessment (IIA) was undertaken as part of the development of the draft HIS (Appendix C). All of the policies and proposals within the draft strategy were reviewed against the IIA framework.

The most impactful policies and proposals were considered to fall within four categories: mental health, economic well-being, healthy choices and employing individuals, and community-focused policies and programmes. The IIA examined the potential for environmental, economic, social and equalities impacts from the Health Inequalities Strategy. Causal chain analysis was used to focus the assessment around the most important issues associated with the policies and proposals in the strategy.

To help to think about the future implications of applying the draft strategy at a local level in different situations, two hypothetical geographical scenarios were developed for 2018-2028. These were:

• An area with a major regeneration site; and
• A borough with high levels of deprivation.

For each scenario, the IIA sought to consider in generalised terms the kinds of changes that might arise in ten years. Five policy and proposal option areas were chosen that related to the major growth and changes anticipated for the scenario and the main impacts identified by the draft strategy as a whole. The potential impacts of the policies and proposals over time were then considered. The IIA made recommendations for strengthening the strategy and enabling it to maximise impact and benefits which have been incorporated into the final strategy.

There are no direct financial implications arising from the publication of the London Health Inequalities Strategy.

The HIS has been prepared in accordance with the statutory obligations which apply to the Mayor when revising any of his statutory strategies (s 41 of the GLA Act) or which are particular to the revision of the HIS (sections 309E-G).

As with all the mayoral strategies, the Mayor must keep the HIS under review and make such revisions as he considers necessary. When revising any of his statutory strategies, the Mayor shall have regard to the principal purposes of the GLA, the effect that the strategy will have on various themes (health, health inequalities, sustainable development and climate change) as well as on the need to ensure consistency with national policies, the UK’s EU obligations and such other international obligations as the Secretary of State notifies the Mayor of. As discussed in section 4 above, the HIS must be consistent with the Mayor’s other strategies and action has been taken to ensure that there has been synergy between all the emerging strategies as best as that can be achieved given the varying stages they are at in the drafting process. It is also relevant that the Mayor has regard to the resources available to implement the strategy.

As set out in section 1, and specific to the HIS, section 309G (2) of the GLA Act provides it shall be the duty of the Mayor and the Health Advisor to collaborate and co-operate with each other generally for the purposes of the preparation or any revision of the health inequalities strategy and in particular for the purpose of ascertaining the issues that are to be identified in the strategy pursuant to section 309E (4) (a).

The various policies and proposals that are to be included in the HIS have been described in section 1of this document. These, in effect, are under the headings of five key aims to address health inequalities in London over the next decade. These are: (1) Healthy Children: Every London child has a healthy start in life - the key ambition is to ensure the wide adoption of the Healthy Early Years London programme, particularly in the most deprived communities (2) Healthy Minds: All Londoners share in a city with the best mental health in the world -the key ambition is for more Londoners to receive training in mental health first aid informed approaches, starting with young Londoners (3) Healthy Places: All Londoners benefit from an environment and economy that promote good mental and physical health- the key ambition is for London to have the best air quality of any global city, with progress fastest in the most polluted areas, benefitting people most vulnerable to the effects of air pollution (4) Healthy Communities: London’s diverse communities are healthy and thriving - the key ambition is to help more Londoners in vulnerable or deprived communities to improve their health and wellbeing through social prescribing (5) Healthy Living: The healthy choice is the easy choice for all Londoners - the key ambition is for all Londoners to be doing the physical activity they need to be doing every day to stay healthy, with efforts focused on supporting the most inactive.

The GLA Act also provides that mayoral strategies in general shall include such of the available policies and proposals as the Mayor considers are best calculated to promote improvements in the health of persons in Greater London and the reduction of health inequalities between persons living in Greater London and contribute towards the achievement of sustainable development in the UK and the mitigation of, or adaptation to, climate change in the UK. This requirement is subject to the qualification that such policies and procedures need not be included if the Mayor considers that any action that would need to be taken as a consequence is not reasonably practicable in the circumstances.

Consultation

The consultation requirements which applied to the HIS are described in section 1 above of this document. The consultation undertaken by the GLA satisfies those statutory requirements. The Report to the Mayor (appendix B) provides full details of the consultation exercise, and sets out officer recommendations as to whether, and if so how, particular issued have been taken into account in the final recommended strategy or have otherwise been addressed.

In addition to the public and stakeholder consultation, section 42B of the GLA Act requires the Mayor to lay before the London Assembly the version of the HIS which he proposes to publish and allow the Assembly the opportunity to pass a motion to reject the HIS within 21 days of the date on which the HIS is laid. The Mayor is, therefore, being asked to approve the final version of the HIS for publication but the final version will first be deposited with the London Assembly in accordance with their Standing Orders. It will only be published if a motion to resolve to reject the HIS within the permitted 21 days is not carried by the London Assembly.

Integrated Impact Assessment

As explained in section 4 above, an IIA was carried out in respect of the draft HIS and formed part of the consultation materials that were made available to stakeholders and the public. The Mayor noted the IIA report when approving the consultation draft version of the HIS and is asked to take it into account when making this decision.

Implementation target

Section 41 (9) of the GLA Act provides that the Mayor shall from time to time set targets with respect to the implementation of the HIS, as he may consider appropriate, having regard to any related targets or objectives set nationally, and any performance indicators set by the Secretary of State, whether nationally or locally, which affect the exercise of functions by authorities involved in the implementation of the strategy. The HIS includes some formal targets.

Publicity requirements

Section 43 of the GLA Act requires that adequate publicity is given to the publication of the HIS.

A copy of the HIS must be sent to each London Borough Council and the City of London Corporation. A copy must also be made available for inspection at City Hall and such other places as the Mayor considers appropriate. An electronic copy will also be available for download via the GLA’s website.

A copy of the HIS may be supplied to any person requesting it for a fee which the Mayor may determine.