MD2406 Health Foundation funded project to tackle health inequalities

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. Section 309F(4) Greater London Authority Act 1999 (“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”. Section 309F(5) GLA Act requires policies and proposals in the HIS 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.

The HIS was published in September 2018 (MD2344), with a supporting Implementation Plan. The London Prevention Partnership Board, a sub-board of the London Health Board, oversees the delivery of the HIS. Key partners for delivery include the NHS, London boroughs, and Directors of Public Health.

Health inequalities are a challenge across the country and are particularly stark in cities and urban areas. Most of the population live in an urban environment. Cities share features that can enable them to take brave and bold action on health inequalities, for example a sense of place and identity, diverse economies, and a unique political mandate. Recent devolution agreements in many areas of England have enabled local authorities to combine, granting them new health and care powers and responsibilities, and in several cases a directly elected Mayor. These developments present urban areas with some specific opportunities to act on determinants of health and to address health inequalities in their region through a place-based approach.

There are currently seven combined authorities with directly elected Mayors (an 8th in progress) as well as the Greater London Authority. These organisations have different powers to address health inequalities. For example, in London this includes the Mayor’s statutory duty to produce a Health Inequalities Strategy for London.

In December 2018 the Health Foundation agreed to provide £314,400 funding to the GLA for a three-year project. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK, with a strong focus on wider health determinants. The full funding will be subsequently awarded to an external organisation who will deliver the project. The income will be received by the GLA over three financial years in 2018-19 (£157k), 2019-20 (£126k), and 2020-21(£31k). The method of awarding the funds to an external organisation will be determined in discussion with TfL Commercial.

This project seeks to bring senior leaders in English cities/metropolitan regions with devolved powers and directly elected Mayors (devolved urban regions) together to facilitate learning and acceleration of action to tackle health inequalities. By improving understanding of each region’s priorities, context and approaches to the complex challenges that underpin health inequalities, we aim to improve practice in addressing the social determinants of health across urban England. Further, we seek to support devolved urban regions to act upon the evidence of best practice in addressing social determinants of health inequalities, as recommended by organisations such as the Health Foundation and Kings Fund, and apply it at the city/region level.

This project will include identifying and focussing in on policy areas where we think a devolved region can have greatest impact on health inequalities under the leadership of a mayor. This might include reducing outcomes like violence, child obesity and poor mental health, as well as the overarching interest in healthy life expectancy.

As stated in 1.6 the funds will be awarded to an external organisation who will deliver the project. Most of the funding will be used by the external organisation for the central Policy Officer role. The funding will also provide for a programme management function, administrative support, as well as some other elements (e.g. research support, travel, printing etc).

The Policy Officer will develop relationships and networks between officers in the GLA and other regional authorities to discuss ideas, share learning and good practice, and drive effective action on wider determinants of health in the devolved urban region context. The Policy Officer will develop policy expertise on addressing health inequalities and wider determinants of health in a devolved urban region. This will support the progression of the Mayor of London’s health inequalities commitments.

Senior officers of the Greater London Authority (GLA), Greater Manchester Combined Authority (GMCA), West Midlands Combined Authority (WMCA), Association of Directors of Public Health (ADPH), ADPH London and the Health Foundation will convene in February 2019 to form a leadership group, who will inform a detailed work plan. The draft approach is summarised below (2.6 – 2.11).

This programme of work is primarily about supporting collaboration, facilitating knowledge exchange and practice improvement, within the context of devolved English urban regions. This project will allow space for policy thought, creation and leadership at this level, filling the existing gap in an area of continuing interest and growing importance, including how to apply the existing evidence on addressing social determinants of health and reducing health inequalities in this devolved urban regional context.

Senior Policy Lead - Health Inequalities in an urban region: Central to the programme will be a Senior Policy Officer role (to be recruited) who will facilitate the network and the inter-regional relationships, as well as taking a vital lead role in developing a policy approach to addressing city/urban region health inequalities. This will include mapping the picture in different areas, the levers, the challenges and opportunities, identifying the areas to prioritise, building the relationships with the systems leaders, translating the evidence on addressing determinants of health and closing the gap in health inequalities in city/urban regions, and applying this learning through the network. Through the Senior Policy Officer role, this project would provide a means to accelerate sharing of the considerable learning gathered through the network at pace.

A detailed work plan for year 1 and an overview workplan for years 2 and 3 will be developed as an initial task, with input from the Leadership Group. Activity proposed activity for year 1:

• Project management and set up of governance and advisory structures;
• Mapping of the current picture of health inequalities activity in devolved regions (involving desk-based research and interviews), this will include review of academic and policy papers, national health and prevention policy, the health inequalities picture in regions, regional governance structures and levers, regional partnership work, regional priorities and work programmes; and
• Annual networking event.

Work in years 2 and 3 will build on these initial work streams. Key will be cementing the networks that were initiated in year 1 and continuing to build opportunities for cross-fertilisation of ideas and experiences. There will a specific focus on networking opportunities and enhancing the sharing of evidence and practical experiences in terms of how programmes of work are implemented, where the risks and challenges are, how they might be addressed, and lessons learnt. It is envisaged that the network(s) will continue beyond the life of this project and in year 3 a ‘sustainability’ workstream will be added to the programme. Indicative work areas for discussion as the project progresses are:

• ‘Making it happen’ sessions focussed on implementation and practical challenges;
• Focussed work on specific devolved regional health inequalities priorities (e.g. violence reduction, child obesity); and
• Anchor institutions in cities/urban regions.

Intended outcomes of this project include:

• Improved understanding across the network, between city leaders, and of academics and national policy makers of the landscape of health inequalities in the context of devolved urban regions, how the evidence might be applied, what the priorities are across cities and what is happening in practice;
• Good practice and practical lessons for regions in taking forward work on different areas (i.e. how to implement) are identified and shared;
• Development of national, cross-region network to support sharing and learning in the longer term, and support those with a political mandate to take action;
• An evidence-based shared narrative to support political leaders to prioritise a focus on health inequalities;
• Identification of the opportunities and policy levers created by different levels of devolution, and different approaches across these regions; and
• Identification of and solutions for some of the challenges inherent in tackling health inequalities in a multi-level complex system.

Outputs: There will be a focus on sharing information and understanding approaches and opportunities in depth – sharing practical experiences and advice on managing complex relationships and contexts as experienced in different regions. Some of the information exchanged will need to be done in confidence between the participating authorities, but the providers will work with the Health Foundation and Leadership group to determine appropriate outputs for a wider audience, for example, a report of the work programme might include:

• Report of the mapping, i.e. current picture of health inequalities and work focused on social determinants in English city/urban regions, and a reframing of the current policy agenda and evidence to be applicable to cities/urban regions;
• Example case study(ies) of the approaches that have been developed as a result of this process (if appropriate);
• A toolkit/guide for supporting change to health inequalities at a regional level;
• An exploration of where the potential for addressing health inequalities through further devolution might look like; and
• Roundtable/workshop to share the lessons with wider stakeholders (jointly with the Health Foundation).

Other opportunities to disseminate learning more widely will be explored with the Health Foundation, e.g. reports and events.

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 ensuring 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”.

This project will be focussed on addressing the wider determinants of health. It will reflect the HIS, which is designed to address systematic and unfair differences in mental and physical health between groups of people. This project recognises that different groups of Londoners experience specific inequalities and will focus on reaching the most vulnerable and marginalised. 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 this project, work on wider determinants of health and health inequalities, and the HIS in general is to improve health for all through an approach of proportionate universalism: universal approaches, with additional support in proportion to need.

This project is seen as part of the implementation of the Health Inequalities Strategy (MD2344), sharing practice and learning what works in collaboration with partners across the country operating in similar environments.

Approval is sought for the receipt of £314,400 in grant funding from The Health Foundation towards expenditure related to the Mayor’s Health Inequality Strategy. The income will be received over three financial years in 2018-19 (£157k), 2019-20 (£126k), and 2020-21(£31k).

The funding agreement will be managed by the Health Team within the Health, Education and Youth Unit.

The foregoing sections of this report indicate that the decisions requested of the Mayor concern the exercise of the GLA’s general power of competence under s.30 GLA Act to do such things considered to further, or which are facilitative of, or conducive or incidental to the reduction of health inequalities in Greater London as defined in s.309F ; and in formulating the proposals in respect of which a decision is sought officers have complied with the GLA’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; and
• Consult with appropriate bodies.

In taking the decisions requested, the Mayor 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 (race, disability, gender, age, sexual orientation, religion or belief, pregnancy and maternity and gender reassignment) 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 Mayor should have particular regard to section 3 (above) of this report.

Officers will, subsequent to this MD, consult with TfL Commercial to produce an appropriate strategy to award funding to an external organisation to deliver the project, and ensure that the process complies with the GLA Contracts and Funding Code.