MD2906 Health Inequalities Strategy Work Programme

1.1. The London Health Inequalities Strategy (HIS) sets out the ambitions for London to be a healthier, fairer city, with all Londoners having the best opportunities to live a long life in good health. Working together with the wide range of organisations that have a role to play in tackling the causes of health inequalities, we want to create a city where nobody’s health suffers because of who they are or where they live.

1.2. The HIS was published in 2018 to support this vision. A progress report on the first three years of implementation was published earlier this year, and a new implementation plan for this Mayoral term will be published shortly. The new plan will reflect commitments published in the 2021 manifesto, the health inequalities priorities which have arisen from the pandemic to date and the London Recovery programme.

1.3. The 10-year HIS provides an evidence-based framework for action on health inequalities in London. It is framed around five aims:

• Healthy Children: every London child has a healthy start in life
• Healthy Minds: all Londoners share in a city with the best mental health in the world
• Healthy Places: all Londoners benefit from an environment and economy that promotes good mental and physical health
• Healthy Communities: all of London’s diverse communities are healthy and thriving
• Healthy Living: the healthy choice is the easy choice for all Londoners.

1.4. COVID-19 has had a significant impact on London’s health inequalities, and the GLA Health & Wellbeing team’s work programme (see MD2650, MD2688, MD2704, and MD2799) has been reviewed to ensure that work is focused on the ongoing and emerging needs of Londoners. The London Recovery programme has been established in response to the impact of the COVID-19 pandemic, and seeks to address the following grand challenge for London: to restore confidence in the city, minimise the impact of COVID-19 on communities, and build back the city’s economy and society. The programme has established nine recovery missions, two of which focus explicitly on health. Health and wellbeing is also a cross-cutting principle for consideration across all the missions.

1.5. Activity to tackle health inequalities is progressed through partnership working, with the Mayor of London having a health leadership role. The London Health Board and the Health Equity Group (co-chaired by the statutory health adviser) are key bodies to drive forward and support London activity.

1.6. The items in this decision relate to GLA Health & Wellbeing team activity to support implementation of the HIS. But they represent only a small part of the delivery of the HIS, with delivery also sitting in other parts of the GLA and wider GLA Group, and with partners. A fuller summary of the delivery will be published in the forthcoming HIS Implementation Plan.

1.7. Expenditure will take the form of grant awards or payment for services procured, depending on the nature of the work concerned and in line with relevant GLA procedures including the GLA’s Contracts and Funding Code.

2.1. The table below gives an indicative breakdown of activities for this programme and the decisions being sought for proposed expenditure across the next three financial years. The GLA Mayoral Budget for 2022-23 and 2023-24 has yet to be approved; therefore, the proposed expenditure in future years would not be committed until final budget approval is confirmed.

HIS implementation

2.2. 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 below.

2.3. HIS partnership programme (£25,000 in 2021-22; and £50,000 in 2022-23 and 2023-24): Activity to support the implementation of the London HIS with London partners. This will include a series of at least five workshops during 2022 and 2023, and other collaborative activity informed through partnership working, to progress health inequalities priorities. It will include consultancy/research projects to: support partnership engagement in the health inequalities programme; and build opportunities and evidence to support the delivery of the priority actions in the implementation plan.

2.4. HIS programme support expenditure (£16,000 in 2021-22; and £25,000 in 2022-23 and 2023-24): Resource to support memberships and journal subscriptions, as well as small ad hoc expenditure relating to the work programme, such as travel, accommodation, catering, design and graphics, printing, and room bookings.

2.5. HIS data and measurement (£75,000 in 2021-22): Resource to support work to develop the evidence base and explore the data around health inequalities in London, including in relation to priorities of the London recovery programme.

2.6. Exploratory work for new HIS-related manifesto commitments (£20,000 in 2021-22): Resource to support work to progress manifesto commitments relating to the HIS. In 2021-22 this resource will support the implementation of the Mayor’s manifesto commitment to remove harmful gambling advertising from the TfL network. The funding will be allocated to commission an external academic partner to review and/or add to the evidence base for the public health impacts of gambling advertising.

HIS policy and programmes

2.7. Social prescribing: The Mayor has committed to supporting the roll-out of social prescribing, ensuring it is accessible to all Londoners, particularly those who could most benefit from it. Social prescribing is a means of referring (for example, by a GP) or improving access to a range of social support and activities delivered in the community (often by the VCSE sector) to the end of improving people’s health and wellbeing. Social prescribing was one the five key ambitions of the HIS.

2.8. Work on social prescribing has been delivered in partnership. In 2019 the GLA, Healthy London Partnership (HLP) and the London Social Prescribing Network published ‘Next Steps for Social Prescribing’, which set out a partnership approach for growing social prescribing in London. This was developed with extensive consultation, particularly with the VCSE sector. Since then, social prescribing has been mainstreamed within the NHS Long-Term Plan and over the last 18-24 months link workers have been appointed in every GP practice. During the pandemic the GLA, working with partners, delivered additional networking capacity across the system to support different sectors and allow social prescribing activity to be shared.

2.9. With social prescribing now widely available in London, the Mayor’s support for social prescribing has been focusing on the areas where we can best add value:

• supporting the VCSE sector to deliver social prescribing as an equal partner
• promoting and supporting collaborative work between boroughs, health and VCSE partnerships working
• championing the future development of social prescribing in London
• supporting and embedding social prescribing quality and impact across the GLA.

Activity across each of these areas is outlined below.

2.10. Supporting VCSE delivery (£25,000 in 2021-22; £33,000 in 2022-23; £35,000 in 2023-24): This resource is for the continuation of funding for the VCSE social prescribing network. The GLA commissioned London Plus to deliver the network in 2019-20. London Plus is the main organisation within the capital that supports VCSE organisations to connect, share learning and collectively use their voices to influence and change policy. The network has increased VCSE status in social prescribing in London, with the Network Coordinator sitting on all major London social prescribing forums and some national forums. The membership and influence of the network continue to increase. The network is an enabler for several recovery missions, through bringing together the voices of the VCSE sector. It is especially relevant to the Building Stronger Communities, and Mental Health and Wellbeing missions. A multi-year approval is requested as this involves a dedicated role. Further we are keen to provide London Plus as a VCSE partner, and the network as a key part of the London social prescribing infrastructure, some stability.

Previous approvals: DD2419 approved expenditure for the establishment of the network, and MD2688 agreed a variation to that expenditure.

2.11. Collaboration to improve access to social welfare legal advice (SWLA) (£40,000 in 2021-22; £50,000 in 2022-23 and 2023-24): There is good evidence on the impact that access to SWLA can have on health and wellbeing. This work programme aims to increase collaboration between the health sector and SWLA provision. It will directly support the Robust Safety Net recovery mission. It is informed by previous work commissioned by the GLA on SWLA in health settings, including the commissioned report, “Collaboration between social prescribing and SWLA services in healthcare setting”, published January 2021; webinars held in January and March 2021; and case studies. This funding will be used across three years to support the Robust Safety Net mission activity with:

• funding a SWLA training offer in health (and potentially other) settings, to upskills those involved in social prescribing, and identify barriers to commissioning SWLA in health settings
• a stretch funding pot for SWLA partnerships funded through the Robust Safety Net programme to expand the scope of their work to include health settings or social prescribing networks
• commissioning a learning partner, funding a dedicated learning implementation role, and/or funding learning/stakeholder activity to use and embed learning from the project and the Robust Safety Net mission as a whole.

A multi-year approval is requested to reflect the multi-year commitments of the Robust Safety Net Mission, and allow us to ensure health is a key sector embedded in the Robust Safety Net programme, to ensure we are maximising the potential health benefits.

Previous approvals: MD2323 – Health Team Work Programme 2019-20; ADD2492 – Social Prescribing and Mental Health.

2.12. Championing future development and embedding social prescribing in the GLA (£40,000 in 2021-22; £40,000 in 2022-23; and £20,000 in 2023-24): There are considerable opportunities to better embed social prescribing in work that is happening across the GLA. A commissioned project nearing completion seeks to bring together a range of examples of how GLA-led activities have supported social prescribing, drawing lessons from them to further support this practice. This project will identify case studies and good practice; and make recommendations for further activity to enhance the GLA social prescribing engagement with VCSE, link workers, and commissioning and evaluation activity. This resource will support the implementation of recommendations, and over the next few years will resource related work to support the embedding of social prescribing into GLA work programmes identified as having considerable potential for further development – for example, adult education and the environment programme (i.e. green social prescribing).

Previous approvals: ADD2492 – Social Prescribing and Mental Health.

2.13. Community development in health: community of practice network and masterclasses (£35,000 in 2021-22; £45,000 in 2022-23; and £40,000 2023-24): This builds on an existing work programme, to share learning and best practice on what works at the local community level to build healthy and resilient communities. Community development as an approach is recognised as an effective way to improve health outcomes, including for Black, Asian and minority ethnic communities who have experienced a disproportionate impact of COVID-19, and experience more barriers to accessing healthcare and support. A successful masterclass programme was delivered in 2019, with participants subsequently brought together to form a network. This resource is allocated to support the continuation of the masterclasses programme and support the network. These activities will provide strategic support to enable more community development in health locally and show the Mayor’s leadership. The funding will be used for the following:

• To support the development of a community of practice network to promote health-focused community development, and support practitioners to share good practice across London. Outputs will include work across integrated care systems (ICS), network meetings and peer-to-peer learning events.
• To deliver the Community Development for Health masterclass over two to three years with a cohort of an estimated 100 delegates each year. This will work in partnership with the wider health system to seek participants from PHE, NHS, VCSE sectors and across ICS areas.

A multi-year approval aligns with the HIS implementation plan which runs from 2022-2024. Community empowerment and collaborative practice with communities is a theme throughout the HIS. The community of practice network provides a London wide delivery mechanism to engage across sectors and the masterclass provides alumni for the network.

Previous approvals: MD2323 – Health Team Work Programme 2018-19; MD2439 – Health Team Work Programme 2019-20; and MD2688 – Health Team Work Programme 2020-21. This activity will be further supported by £25,000 approved in MD2704 – Recovery Fund for the Health Community Leaders.

Regional Health Inequalities Project (Health Foundation grant)

2.14. We are also seeking a decision on the receipt and expenditure of £26,000 from the Health Foundation on a project to support regional action to tackle health inequalities. This is an extension to the grant agreed in MD2406. This income is to be spent in 2021-22.

2.15. In 2018-19, a three-year work programme was agreed with, and grant-funded by, the Health Foundation, to support the acceleration of activity on health inequalities across England’s devolved regions, via Mayoral-led authorities. The Health Inequalities project underwent a significant redesign following the disruption created by the COVID-19 pandemic. This redesign has been positive in reframing the project and achieving significant learning over a relatively short period.

2.16. In September 2021 it was agreed that the Health Foundation would provide additional monies to support the progression of the project till the end of 2021. All the resource provided in this grant will be spent on the project in the 2021-22 financial year, and any unspent resource will be returned to the Health Foundation.

3.1. Under section 149 of the Equality Act 2010, as a public authority, the GLA must have ‘due regard’ of the need to:

• eliminate unlawful discrimination, harassment and victimisation
• advance equality of opportunity and foster good relations between people who have a protected characteristic and those who do not.

3.2. The Mayor’s Equality, Diversity and Inclusion (EDI) strategy sets out how the Mayor will help address the inequalities, barriers and discrimination experienced by groups protected by the Equality Act 2010. There is considerable alignment between the EDI strategy and the HIS, with both seeking to take action on the drivers of inequalities – such as income, air quality and housing – that are framed in the HIS as the economic, social and environment determinants of health. The population groups outlined in the EDI strategy – those with protected characteristics – are often the same as those we focus on in the HIS, who experience poorer health outcomes. As well as this alignment, there are a number of objectives in the EDI strategy on which the Health and Wellbeing team specifically provide updates for the EDI action plan, and feed into the Mayor’s Annual Equality Report (MAER). This includes objectives on mental health. Publication of the MAER is a legal requirement and outlines the arrangements put in place by the GLA over the last financial year to demonstrate that due regard has been paid to the principle that there is equality of opportunity for all people in the exercise of the Mayor’s general powers.

3.3. An Integrated Impact Assessment, which included an Equalities Impact Assessment (EIA) within its scope, was conducted as part of the development of the HIS. This identified major positive and negative impacts of the programme for groups protected under the Equality Act 2010; and proposed ways to strengthen benefits, mitigate negative impacts, and identify issues concerning the four cross-cutting themes under the GLA Act 1999. The HIS was adopted in October 2018 and the Integrated Impact Assessment was published at the same time. An example of how the HIS was adapted to reflect the EIA relevant to this MD was ensuring social prescribing work considered older and more disadvantaged Londoners. The EIA also recognised that many of the policies and programmes in the HIS specifically targeted low-income Londoners.

3.4. A series of 14 population health inequalities indicators are monitored as part of the implementation of the HIS. These demonstrate the gap in outcomes between different populations on key metrics. There is some overlap between these measures and those reported on for the EDI strategy, e.g. child obesity.

3.5. Further work has been undertaken in the last year to understand the impact of COVID-19 on health inequalities, exploring the health impact on different populations. A number of research reports were also published which identified the impact on specific vulnerable cohorts. These included the PHE reports COVID-19: review of disparities in risks and outcomes and COVID-19: understanding the impact on BAME communities. The Mayor commissioned a Rapid Evidence Review to gain a better understanding of the impact for London: Inequalities in relation to COVID-19 and their effects on London. The Deputy Mayor for Communities and Social Justice convened a series of virtual roundtable conversations and community meetings with groups and community leaders between April and September 2020. The 21 roundtables and community meetings reached and engaged with 250 civil society and community groups. The report, Map of Community Views: COVID-19, summarises the findings. A monthly Community Response Survey provides real-time feedback on changes in voluntary and community-sector priorities and issues based on their community contacts. This learning continues to inform the work programme of the Health and Wellbeing team. For example, these pieces of work have highlighted financial insecurity and the importance of improving access to SWLA, which has informed the social prescribing work programme.

Key risks and issues

4.1. Risks are assessed and managed on a programme basis. Cross-cutting and major risks are reported quarterly through the GLA’s corporate performance management process. At the time of writing, the major risks are as follows:

4.2 The GLA health programme is directly related to delivery of the Mayor’s HIS, a statutory duty under the GLA Act 1999.

Impact assessment and consultations

4.3 Impact assessments have been conducted on the key elements of the programme, as detailed above.

4.4 The HIS was subject to extensive consultation to inform its development in 2017 and 2018. The work programme has further been informed by community engagement over the last 18 months.

4.5 There are no known conflicts of interest to note for any of those involved in the drafting or clearance of this decision.

5.1 Approval is being sought for receipt of £26,000 of external income from the Health Foundation as a funding contribution to support the Regional Health Inequalities Project.

5.2 Approval is also being sought for expenditure totalling £765,000 for the Health Inequalities Strategy (HIS) programme over 3 financial years (2021-22, 2022-23 and 2023-24) as detailed in the table under paragraph 2.1 and summarised below.

5.3 Of the £765,000 total expenditure: £105,000 will be funded by the 2021-22 Social Prescribing Budget, £171,000 will be funded by the 2021-22 HIS Mobilisation Budget and £26,000 by 2021-22 external income funding from the Health Foundation; £463,000 (£243,000 in 2022-23 and £220,000 in 2023-24) will be funded by the HIS Mobilisation budget. All budgets are held within the Health Units budget allocation for each respective financial year.

5.4 This decision is requesting funding that is not yet assured for 2022-23 or 2023-24. The GLA may be subject to future funding cuts and the expenditure planned here may not be affordable. To this end, break clauses have been incorporated into contracts. Officers need to be aware that this programme will not be subject to any more favourable treatment in future funding rounds than programmes that have not requested funding for future years, meaning the break clauses may well have to be exercised. The funding allocation in future financial years will be subject to the normal annual budget setting process and is subject to change.

6.1 The foregoing sections of this report indicate that the decisions requested of the Mayor fall within the statutory powers of the Authority to promote and/or to do anything which is facilitative of or conducive or incidental to 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:

(a) pay due regard to the principle that there should be equality of opportunity for all people

(b) 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

(c) consult with appropriate bodies.

6.2 In taking the decisions requested of him, 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.

Funding

6.3 The officers are seeking approval of a budget of £739,000, part of which will be used to fund the projects of third-party organisations. To that end, the officers are reminded to comply with the requirements of section 12 of the Authority’s Contracts and Funding Code (the “Code”) when allocating funding to third parties. Furthermore, the officers must ensure that an appropriate funding agreement be put in place between the Authority and the recipients of the funding before any part of the funding be paid.

Procurement

6.4 The officers are reminded to comply with the requirements of the Code, when the Authority procures services or supplies in furtherance of the projects related to the budget the subject of this decision form.

Receipt of funding

6.5 The second decision in this decision form seeks approval for the Authority’s receipt of £26,000 of funding from the Health Foundation. The officers must ensure that they comply with any conditions attached to the grant of funding by the Health Foundation.

7.1 A detailed business plan for the work of the Health and Wellbeing team will be developed, setting out the full range of programmes, policy and advocacy work the team plans to undertake in 2021-22 alongside a timeline for each specific deliverable and a longer term plan to 2024. The below table summarises milestones/timeframes for delivery in 2021-22.

• The London HIS 2018-28: /programmes-strategies/health-and-wellbeing/health-inequalities-strategy
• The London HIS Implementation Plan 2018-2020: /sites/default/files/his_implementation_plan.pdf
• HIS Annual report 2018-19: /sites/default/files/his_annual_report_1819_final.pdf
• HIS progress report 2021: /sites/default/files/his_update_august_2021.pdf
• The HIS Consultation Integrated Impact Assessment: /sites/default/files/the_mayor_of_londons_health_inequalities_strategy_iia_report_-_final_23.08.17_0.pdf
• Our Vision for London: The next steps on our journey to becoming the healthiest global city (2019) /sites/default/files/11448_hlp_london_vision_-_annual_report_2019_full_version.pdf
• Next Steps for Social Prescribing in London: /sites/default/files/social_prescribing_next_steps_document.pdf
• COVID-19: review of disparities in risks and outcomes: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf
• The impact of COVID: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf
• COVID-19: understanding the impact on BAME communities: https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities