Category Archives: Local Government

Alan Hall

Speaking the truth to power is always a risky business.  No more so than when considering how millions of pounds of public money should be shovelled into developments and contracts.

Local government overview & scrutiny has been with us since the Local Government Act 2000 and the advent of the cabinet system and executive mayors. In the case of executive mayors –  a single politician making the decisions to spend millions of pounds of public money albeit with the advice of officers and an appointed cabinet – it is easy to see how local councillors could feel disempowered if they are not allowed a proper say on the decisions taken. Overview and scrutiny committees can provide a proactive, pre-decision mechanism for proper political involvement and public engagement. This scrutiny system improves and refines decisions, weeds out poor proposals and advances evidence-based policies.

Good council scrutiny can also allow for challenge to government too. Following the roll-out of austerity and public spending cuts led a review of the London Borough of Lewisham’s emergency services which reported in 2013.

The review showed that significant funding cuts had put services under severe strain, with an impact on preventative services and areas like probation too.

The process allowed for proper scrutiny of these changes both by the council and external public agencies and, during the review, Lewisham Council successfully challenged Jeremy Hunt, secretary of state for health over the proposed closure of Lewisham hospital’s A&E department.

An example of proactive scrutiny came after the tragic Grenfell Tower fire. All housing authorities rightly reviewed their housing stock and hopefully their policies. As a matter of urgency, I wrote to Barry Quirk the then chief executive of Lewisham council to ask that a fire and risk assessment be made of all tall buildings and I invited the borough’s fire commander to address us to give the public and the council the assurances it needed.

Party politics will, of course, play a part in any local government setting and it is naive to think that elected politicians forget their party in scrutiny. But, as a recent Communities & Local Government Select Committee report on local authority scrutiny says, council leaderships have a responsibility to foster an environment that welcomes constructive challenge and debate. I have always held that scrutiny meetings can provide a platform to explain and publicise good policy initiatives and challenge assumptions or ‘group think’.  Let’s imagine the alternative – complete, untrammelled power of the executive.

Instructing scrutiny members how to vote and threatening them with the whip does not foster the constructive challenge we need. Scrutiny committee members need to be able to hold their cabinet colleagues to account.

But if proper scrutiny is to play a full part in effective local government, we will need a culture shift.  The scrutiny process – sometimes seen as the trainspotting of the council world – needs to be valued every bit as much as executive decision-making. This parity of esteem should mean getting access to the resources needed to do the job – including professional and independent advice.

The Financial Reporting Council and the Institute of Chartered Secretaries & Administrators advise that a company’s board should make funds available to their audit committee to enable it to take independent legal, accounting or other advice when the audit committee reasonably believes it necessary to do so. However, scrutiny committees have no such right. Indeed I have requested independent legal advice in the past and an eminent QC has given an opinion supporting a refusal of this request. I believe this change would help proper scrutiny when a council’s legal officers are advising the executive on hugely complex and controversial developments and contracts. It would solve an inherent conflict of interest.

Meanwhile, the government has responded positively to the select committee’s recommendations that overview and scrutiny committees should report to their full councils and not just the executive and that officers should provide impartial and professional advice. That after 18 years of local government scrutiny these recommendations need to be made at all is telling. There is a long way to go before there is anything like parity of esteem between the executive and scrutiny functions.

I helped pilot scrutiny arrangements in Lewisham in 2001 and more recently I am pleased to have had the endorsement of Lord Kennedy – and, somewhat to my surprise a government minister Lord Young – when I led the questioning of a compulsory purchase order around Millwall Football Club’s ground in South East London. The lesson I have learnt is that scrutiny is best when gathering evidence from beyond the usual officers and paid advisors. In the words of an Ofsted inspector who I gave evidence to recently: “Triangulate – don’t only listen to your officers.”

Council scrutiny is a crucial part of our local democracy. It benefits councils and residents alike, contributing to better decisions, better use of public resources, better public engagement and – ultimately – better services.

this article was originally published by The Fabian Society

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In recent days there has been a storm about the recently announced 2016/17 local government grant settlement from central government. The creation of a new £300m relief fund will mainly be used to help Tory-run councils, like David Cameron’s Oxordshire County Council, with Labour leveling the accusation that this is to buy off Tory MPs.

I will leave it to others to form a view on whether this is fair or not. But this whole storm did get me thinking about the scale of the cuts not just for this year, but over the past few years, since the Tories came to power.

So I grabbed hold of the 2011/12 figures for “council spending power” and compared them to the recently announced 2016/17 figures and worked out the percentage cut in spending power for each council. I picked 2011/12 as a base year this was the first full council financial year the Tories were able to fully influence after being elected.

I decided to look only at the 152 County Councils and Single Tier Councils (e.g. London Boroughs, Unitary Councils, Metropolitan Boroughs etc) as they make up over 93 per cent of all council spending. There are 201 district council but they make only about 7 per cent of total council spending. Hence looking only at the “Upper Tier” councils as this made the analysis more focussed.

The thing I wanted to test was the theory that the most deprived councils were worst hit. So I took a trip over to the Office of National Statistics (ONS) English indices of deprivation for 2015 website. Here I got the Index of Multiple Deprivation (IMD) average score breakdown by council areas and then  used the rank of the average IMD score to plot percentage change in revenue spending power using versus the IMD average score rank.

Below is the very telling plot of this data. Note councils with low ranks on the IMD (those plotted to the left) are the most deprived and those with high ranks on the IMD (those plotted to the right) are the least deprived.

Upper Tier Council Cuts versus IMD

This graph shows a strong and clear relationship that the councils that are serving the most deprived communities have suffered the largest cuts over the past five years. This very strong relationship is evidenced by the high R2 value (or coefficient of determination) of 0.81. A value of 1 would indicate a perfect fit on the line of best fit, and a value of 0 would mean the data does not fit the line in any way. A value of 0.81 shows a strong and clear fit/relationship.

So there you have it: the numbers don’t lie. The poorest and most deprived have suffered the largest percentage council cuts. The poor have been robbed to subsidise the rich.

If you want to check the data and my calculations you can download it here.

First published on Ravi’s own blog More Known Than Proven

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Integration. Prevention. Personalisation. The buzzwords that indicate the reforms our health and care system needs are as widely recognised as they are overused. So too are the problematic features of current service provision: fragmentation, barriers and silos. The challenge is not one of rhetoric, but of moving beyond words to practically forge a system that works for people – and enables us all to live healthier, happier lives.

The context is a challenging one  – on this there is also widespread consensus. People are living longer, and many more with long-term, complex conditions. The medical advances and increased life expectancies we can all celebrate mean that demand for services has evolved from the point when the National Health Service was first established in 1948. A hospital-based model set up to treat illness when life expectancy was 65 is now being required to tackle challenges it was not designed to cope with. Pressures are created as a consequence of this: A&E wards are struggling to cope with too many crises that could have been avoided if appropriate care was in place, and hospital beds are over-relied upon because community based infrastructure is insufficient. The funding cuts to local government of 40 per cent over the last parliament have had an inevitable impact on social care provision: the coalition government’s approach to salami-slicing Whitehall budgets without reform exacerbated the situation.

Against this backdrop, the announcement that responsibility for health and social care would be devolved to statutory organisations in Greater Manchester was certainly a bold move. The circumstances of the announcement months before the general election distracted from much of the substance of the proposed framework, which was to enable joint decision-making on integrated care to support physical, mental and social wellbeing. The intervention also exposed some of the fault lines that exist in debates over health and care reform: between centralist and localist perspectives, and between the medical profession and the local government sector.

As a consequence there are a few myths around the content and the implications of the Memorandum of Understanding which set out the terms of the devolution deal in Greater Manchester that need to be addressed, prior to a realistic appraisal of the measures. Some media coverage referred to the agreement as a local government “takeover” of the NHS. In fact, the frame – work was developed between Greater Manchester partners together  – 12 NHS clinical commissioning groups (CCGs), 15 NHS providers and 10 local authorities  – and each will retain their existing statutory responsibilities. The parties to the agreement are the Greater Manchester CCGs and local authorities (collectively known as GM), and NHS England. The mischaracterisation of the approach reflects precisely the obsession with professional hierarchies and sector-based territorialism that true integration needs to break through for new arrangements to be more than the sum of their parts.

Fears have been expressed in some quarters that the measures herald the end of the “N” in the NHS. However, the first principle of the agreement is clear that “GM will still remain part of the National Health Service and social care system, will uphold the standards set out in national guidance and will continue to meet the statutory requirements and duties, including those of the NHS Constitution and Mandate”. The charge that the creation of new models of inclusive governance and decision-making would equate to the dissolution of a national system is ill-founded. The NHS has always been delivered in practice by local units such as primary care trusts, which lacked strong public accountability or visibility but worked within geographic and bureaucratic boundaries to make decisions about resource allocation and service provision. When considering the ‘N’ in the NHS, we need to be clear how this fits with the aspiration to craft a system suited to whole person needs, which are by definition different. What balance should be struck between national ‘one-size-fits-all’ rigidity on the one hand, and responsiveness to the needs of people and places, on the other? A public service reform discussion about the role of the national and the local very often quickly alights upon the phrase ‘postcode lottery’ in the negative  – this is interestingly most often used with respect to local inputs rather than variations in outcomes nationally. The postcode lottery that people living in Greater Manchester should be most concerned about is the fact that they can currently expect to live nine years less than the average person in England. This is the motivating force behind the new framework being created by GM partners: tackling the existence of some of the worst health outcomes in the country  – outcomes which have emerged and persist under a centrally-accountable national system.

The devolution agreement, while not in itself an automatic shift to positive outcomes, presents real opportunities for transformation beyond the existing baseline. Taking the starting point of making an analysis of whole population health needs across Greater Manchester, partners can work towards the twin objectives of closing the health inequalities gap – moving from having some of the worst health outcomes to having some of the best – and aligning provision to prevent ill health and promote well-being, from early age to later life.

For the first time, strong democratic accountability puts local people at the heart of the emerging new framework. Where previously decisions would be taken by remote bureaucracies or distant Whitehall departments, they will now be taken involving democratically elected representatives. This can inject a new responsiveness to the local system which will be driven by stronger direct incentives to evolve to meet people’s demands: good access to high quality, joined up services which provide the right care at the right time. GM partners are already focussed on ensuring early, tangible benefits for people which also begin a shift to wider systemic reform, such as proposals to offer seven days a week GP access by the end of the year and a Greater Manchester-wide plan to join up fragmented dementia services.

While the devolution deal does not bring with it any more or less funding – the £6bn package identified refers to existing resources – a more strategic approach across Greater Manchester can seek to make the best use of these by allocating them more efficiently and effectively. Full place-based commissioning and delivery can ensure public investment is committed on the basis of shared intelligence and is geared to provide the right balance between medical intervention and social support. The GM framework is an opportunity to develop a more coherent long-term strategy to ease pressure on hospitals, while building up services in the community that bring health and social care closer to people’s homes. This will mean removing funding ring fences to make sure funding goes where it is needed locally, identifying duplication caused by service silos, and strengthening formal collaboration between providers. New budgeting models such as year of care funding can be developed, which begin to engineer a system-wide shift away from a focus on single episode and crisis treatment towards longer term preventative care. This can all create space for precisely the innovation and adaptation healthcare systems need: a research, innovation and growth strategy is a major strategic thread through GM partners’ joint work and they are prioritising the early implementation of an academic health science system.

Creating a preventative whole-system approach that shifts from treating illness to promoting wellness involves recognising individuals not as patients but as people. In a different relationship with statutory services, individuals have responsibility for their own health outcomes but are also given the right support. Traditionally, building-based health services like hospitals and GP practices focus on treating illness and operate largely in isolation from wider provision that impacts on good health outcomes such as employment and housing. There is now a real opportunity to align priorities across services and within communities. For example, poor health is too often a barrier to sustained employment, so another early implementation priority from the GM partners is a new programme to help people with mental health conditions get back into work.

Stakeholders in Greater Manchester are continuing to develop the relationships, trust and mutual respect between the professions and services involved. Nonetheless, there are real risks to the new approach which will need to be recognised and managed as the process evolves.

First, the funding context within which the GM partners operate is something of a burning platform. It won’t be until the new Conservative government’s first comprehensive spending review that partners will have confirmation of what resources they have to work with, and how longterm a settlement they can predicate their plans on. A strategic business case will be developed by the end of the year which will need to find a way to bridge financial gaps, which will be no small challenge in the context of further austerity.

Second, the huge ambition set out in the early Memorandum of Understanding was matched by an extremely tight timetable for the translation of these principles and framework into action and outcomes. Partners are already part-way into a ‘buildup year’ ahead of full control of health and care budgets in GM by April 2016. While a roadmap and delivery plan are to be developed and agreed between the partners and wider stakeholders, governance arrangements will be agreed in parallel. A careful balance will need to be struck between moving forward where possible while also ensuring that effective system-wide leadership is forged. Governance arrangements will need to simplify accountability rather than add to complexity. They must be robust enough to realign accountability for the use of public resources sufficiently to meet the huge ambition of the framework.

A priority within all of this is to ensure constant and substantive public engagement and involvement: both in the process of devolution itself, and on an individual level in relation to health needs. There will be a new responsibility for local politicians to articulate the ambitions of the GM partnership and ensure that public dialogue focusses not simply on institutional arrangements but on health outcomes. The latter must remain a driving force for partners as well as a measure of their success. Public engagement shouldn’t happen solely through democratically elected institutions but that a new transparency and accountability is created across the whole health and care system so that people have greater opportunity to become genuinely more involved and engaged in decisions which affect their lives.

GM partners are not complacent about the scale of the challenge they face. As the business case is developed they will need to identify the risks and ensure plans are in place to mitigate and overcome them. There is a shared recognition that they have a unique opportunity to move beyond traditional ‘vertical’ organisational silos and pioneer the development of ‘horizontal’ arrangements across a place which have more potential to tackle demand pressures and create more responsive services. The ultimate prize motivating all involved would be to overturn the trajectory of health inequalities which a centrally accountable system has failed to. Then words like ‘integration’ and ‘prevention’ would move from being just aspirations to standard practice.

This was first published by the Fabian Society

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The Chancellor of the Exchequer has announced a £200 million in year cut to the public health budgets in England and the Department of health is holding a snap consultation over the summer how to axe the budgets.

Councillor Alan Hall, who sits on the governing body of London’s Kings College Hospital and also chairs Lewisham Council’s public scrutiny function, said: “This is a cruel conjuring trick that will directly damage public health services. The Chancellor has slashed them to the bone and now he’s cutting through the bone itself.

“Because he’s transferring the services from the NHS to local authorities he thinks that we won’t notice. But they are still the same services and public health will suffer.

“We have had scarlet fever in children at record levels this year and this is the work of public health clinicians locally. Most of Lewisham Council’s health budget is tied up in NHS contracts and axing £1.5 million in this financial year will affect services.

“He’s cutting preventative health care and so will inevitably put greater strain on the NHS. This damages not only the poorest communities but it damages all of us that benefit from preventative health services. It’s a cruel con-trick that will backfire on all of society”

The Public Health budget was directly run from the NHS but transferred to local councils in 2013 with child health service budgets transferring this year. The public health budget  funds many direct NHS services such as sexual health clinics in local hospitals, health protection, drug and smoking healthcare and children’s health programmes like promoting vaccinations and breast feeding.

Local authorities up and down the country are waking up to the consequences of the announcements by the Chancellor of the Exchequer on 4th June 2015. The Department of Health launched a four week consultation on 31st July what it describes as a technical consultation on how to cut £200 million in year from England’s public health budgets previously agreed for this financial year 2015-16.

The consultation document called: Local authority public health allocations 2015/16: In-year savings reveals that Lewisham is earmarked for an ‘in-year’ cut of £1.5 million pounds.

This was first published on Alan Hall’s own blog.

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The transfer in 2013 of significant public health responsibilities and funding for the over fives was, rightly, heralded as one of the best local government-related decisions of the last Parliament (although, to be honest, there weren’t that many to choose from). And since that time we’ve been working hard to negotiate the follow-on 0–5 healthy child programme, included within it the Coalition Agreement priority of an enhanced Health Visitor resource, personally mandated by the PM.

At an otherwise pretty grim time for councils, we celebrated the “coming home” of responsibilities that had, more than 150 years ago, first defined local government as being principally about the health and wellbeing of our citizens and their communities. Indeed, we even took in our stride the otherwise anathema-like criterion of the money being subject to a ring-fence.

And we lauded this progressive change not just for its potential to enable all our functions to be redefined and reworked in the light of these new “health of the public” duties, but we loved the unexpected and increasingly rare opportunity to salvage something of our commitment to prevention and early intervention which was being undermined by the swingeing reductions being made to other key sources of “early help” revenue (notably the DfE’s “hot knife through butter” approach to the EIG).

So, the recent announcement by the Chancellor that £200m is to be swiped in-year from our grants, just a few months before the 0–5 transfer, has left us – and apparently the Department of Health and Public Health England – deeply troubled. The sense of disbelief and, amongst the more melodramatic, outrage wasn’t just because we thought we might have balanced our books in 2015-16; no, it was because we picked up a rumour that the cut was to be made both deliberately against non-NHS activity and also specifically against this grant. Local government, and only local government, must take the hit. Whether or not the latter is true, it is clear that the former is accurate – protection for the NHS is to be ensured.

Or is it?

As we work our way through the likely implications locally with our health colleagues (possibly £6.4m for Birmingham, by-the-by) – who are equally bemused and angered – what is clear is that pretty much all of the 2015-16 allocations are tied up contractually. And large numbers of those contracts are – you guessed it – with the NHS, notably Community and Mental Health providers.

So, this cut has three consequences attached to it: it will, as seemingly intended, permanently reduce the DH’s DEL as it pertains to the public health grant and, consequently, further impair councils’ ability to invest in upstream interventions. But it will also put more pressure on the NHS at a time when it least needs it.

Why would the Government want to do this? Well, we know that deficit reduction is the fig leaf for an appetite to shrink local government, so perhaps there is no real surprise in yet another cut – although, clearly, the rules of the funding game are that there are no rules and, if this is the case, we should expect further in-year reductions to play havoc with our attempts to plan and set budgets.

But what councils and their partners really don’t get is why it makes sense to anyone to introduce this kind of cut when it clearly undermines the otherwise ferocious determination to protect the NHS. Maybe, along with much else that we are seeing in the early legislative programme of the new government (for example, in the Housing Bill), decisions are being implemented that were never intended to get this far. Obviously, it is bizarre that anyone would bring forward ideas that they wouldn’t really want to put into practice in the first place; but this is not as strange as then seeing them through anyway. Let’s hope that this is just an early phase of cognitive dissonance and that, as Parliament progresses, there will be no more cutting off of noses to spite faces.

For now, however, it does seem that a paradise only recently regained is to be a paradise lost.

This was first published on Mark’s own blog.

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As the 2010 Marmot Review (and before that the 2008 WHO report on Closing the Gap) makes clear, significant improvements in population level health, as well as reductions in health inequalities, require actions that tackle the social determinants of health. However, traditional public health policy has tended to focus on modifying individual lifestyles, rather than addressing the more fundamental causes.

The suggestions so far put forward as the SHA’s submission to the Labour Party’s Public Health Policy review also largely focus on these downstream determinants. This review process is an ideal opportunity to put forward more upstream, social determinants based suggestions.

Based on the social determinants of health, and my knowledge of the public health evidence base, I would like the following policy suggestions to be considered by SHA council on 26th April, with a view to including them in our submission to the NEC.

Whilst not all of these policies will be seen by everyone as being “politically possible” in the current climate, however, the SHA is a broad coalition and a range of ideas should be put forward in our submission to the NEC. As Maggie Winters pointed out in her recent post – the NHS and the welfare state were set up in much harder circumstances.

The evidence supporting these interventions can be provided to Council on request.

1. Improving control at work

Studies have shown that employees of all grades with higher levels of control over their work (in terms of content, pacing of tasks, decision-making, etc.) have better health. Low control at work is associated with higher rates of heart disease, musculoskeletal pain, mental ill health and mortality – even when other risk factors (such as smoking) are accounted for.

Interventions to improve control at work (for example rotating tasks, flexible working, employee participation in making company decisions, employee ownership/shares) have been found to improve health – with no detrimental effects on productivity.

The last Labour government introduced flexible working for parents and carers, and Ed Miliband has talked about potentially having employees represented on company boards to influence the remuneration of executives. The health literature suggests that these ideas should be extended to involving employees in other areas of the business so that job control is increased. In other European countries, such as Germany, “worker’s councils” are common place in businesses.

2. Enhancing access to public transport

Access to public transport is an important social determinant of health as it is vital in terms of enabling access to employment opportunities, health care, and other services such as leisure services, food banks etc. However, it has decreased since privatisation due to the costs of travel, and the reduction in bus routes. Local government budget cuts have also led to reductions in the subsidies paid to support less popular routes. This is particularly an issue in rural areas, and for lower income groups.

The last Labour Government introduced free bus passes for the over 60s. These should be extended to the unemployed and workless to enhance employability and job search. Central government should provide funds to local authorities to ensure that public transport is continued to be made available in rural areas to connect communities with services.

3. Introducing 20mph zones

Traffic accidents (non-fatal) are higher in more disadvantaged and urban areas (particularly amongst children and outside schools) – perhaps due to the higher volume of traffic in such areas. There is a strong evidence base that shows that reducing traffic speeds from 30mph to 20mph results in a reduction in accidents. Such interventions are relatively low cost (changing signage) but can lead to a 15% reduction in injuries. Targeting interventions outside schools with high accident rates may be particularly beneficial.

4. Creating healthy places

Geographical research has shown that communities with higher rates of obesity also have a higher prevalence of fast food outlets. Gambling is associated with higher rates of debt, as well as with mental ill health. Betting shops, as well as high-cost credit shops, are more prevalent in poorer areas. There have been big increases in the prevalence of betting shops, fast food joints, and high-cost credit shops in local high streets and town centres since the 2007 financial crisis.

Current planning law does not enable local authorities to properly control the number of such businesses in their local areas because health is not currently a reason to turn down planning requests. A Labour Government should increase the power of Local Authorities to shape local high streets by adding health as factor in planning decisions.

5. Implementing a Minimum Unit Price

The connection between ill health and high levels of alcohol consumption are well known. The Marmot Review advocated a minimum unit price to reduce mortality and morbidity associated with high levels of alcohol consumption. Econometric modelling as well as comparative data from countries such as Canada suggest that a Minimum Unit Price could be a very effective intervention and one that is proportionate – impacting most on the consumption behaviours of those most at risk.

6. Reducing Ill-health related worklessness

Rates of receipt of incapacity-related benefits (e.g. Employment Support Allowance) have increased rapidly over the past three decades and approximately 7% of the UK working-age population is now in receipt of such benefits. Policy has traditionally focussed on reducing the benefits paid to such groups, tightening up eligibility criteria or making employability programmes compulsory. There is almost no evidence that such interventions have been effective. This is because policies have seldom tackled the route cause of such worklessness – ill health.

People in receipt of health-related benefits have multiple and complicated long term illnesses and so tackling underlying health issues could be the first step to successful return to work. NICE guidance recommends a ‘health first’ approach (combining traditional vocational training approaches, financial support, and health management on an ongoing case management basis) to improving the health and employment of people with a chronic illness. The evaluation of a pilot ‘health first’ intervention in County Durham, also suggests that taking a more health focused approach can be beneficial in improving the health of Incapacity -related benefit recipients and thereby putting them in a better place to engage in mainstream job-search activities.

7. Healthy Housing Policy

Housing is one of the major determinants of health – indeed in the Atlee Government, Bevan was Minister for Health and Housing. The quality of housing (e.g. damp) impacts on health, as does tenure (with private occupiers usually exhibiting better health than renters). The cost of housing – both in terms of purchasing and renting – has increased well-above inflation in the UK since the early 1990s. Rents are now considered to be extremely high and in some areas simply unaffordable for large swathes of the population. Much of this increase has been taken on by the tax payer in terms of housing benefit – a subsidy to private landlords.

Evidence suggests that making homes warmer can lead to improvements in health. Improved energy efficiency can reduce fuel bills, freeing up extra money to spend on essential items such as food. High rents also take money away from households. Rent regulation could also improve the wellbeing of vulnerable households by again increasing the amount of money available to spend on other items such as food and clothing.

Restoring rent controls would be an efficient way of reducing the housing benefit bill, whilst protecting tenants. Other policies, such as the welfare cap, merely penalise benefit recipients and have no impact on landlord behaviours.

The quality of private rental properties varies widely, but also follows a social gradient with the poorest renters inhabiting the lowest quality properties. Proper local regulation of housing standards would reduce the ill health burden of substandard housing conditions.

The Labour Party has already made a commitment to abolish the Bedroom Tax – these further housing reforms would make a fuller healthy housing policy.

8. Making work pay

Low income is the most important determinant of poor health. One of the great achievements of the last Labour Government was the introduction of the minimum wage. Despite cries from the opposition, there have been no detrimental economic effects, and for a significant minority of the workforce, it represented a large increase in pay. However, it is well known that the minimum wage is not yet a living wage and that in work poverty is still significant: 46 per cent of adults in working families in poverty are in families where at least one earner is paid below the living wage. There is little scope for these adults to work more hours to escape poverty; they will need higher pay. A Labour Government should pass legislation that sees the minimum wage become a living wage.

9. Minimum Income for Health Living (MIHL)

The Marmot Review proposed a minimum income for healthy living so that everyone – whether they are in work or on welfare – would receive enough money/vouchers/support to ensure a healthy lifestyle. This was the only recommendation of the Marmot Review that the Coalition government did not endorse. Research has shown that the value of out-of-work benefits paid to the unemployed can be important factors in whether unemployment leads to an increased risk of ill health. This means that there is a need to improve the value and accessibility of benefits from a health perspective. This has led to calls for a minimum income for healthy living (MIHL) which will ensure that there is a right to a certain standard of living for those on benefits. A Labour Government should examine how to implement the MIHL.

10. Decreasing debt

Although unable to access mainstream credit, many people on low incomes require credit to ‘get by’ and therefore turn to alternative lenders, generally high-cost credit sources (e.g. doorstep lenders, pawnbrokers, and payday loans). In low income households, credit is used to get by as welfare benefits and/or wages are not sufficient.

Debt has also been linked to suicide, poorer self-rated physical health, long term illness or disability, back pain, obesity and health related quality of life.

Credit unions offer low-rate, small loans, and can have a positive influence on the financial capability and wellbeing of their members. To decrease the health problems associated with debt, the Labour Party should look to supporting Credit Unions as well as capping the loan rates of commercial providers.

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This is reproduced by kind permission from the wonderful  Municipal Dreams blog.   @MunicipalDreams

The pioneers of the Socialist Medical Association started by taking over the health functions of the London County Council, and were deeply committed to the idea of Health Centres

‘Salus populi suprema est lex’. Cicero said it fourteen centuries earlier but Southwark Borough Council translated the phrase into English and bricks and mortar and placed it proudly above the entrance of the new Walworth Clinic opened in 1937.

Tablet

The state, by then, had come to recognise some responsibility for the welfare of its citizens but this had been a tortuous and piecemeal process.  Regularly employed male workers might enjoy National Insurance or trade union and Friendly Society benefits.  The poorest were stigmatised still by their dependence on charity or the Poor Law and its vestiges.

In 1929 the Local Government Act turned over remaining Poor Law services to the counties and boroughs.  It was an opportunity for progressive councils to build on functions already acquired – in maternal and infant welfare and tuberculosis care and prevention – to develop comprehensive healthcare programmes for their population. In this way, they would prefigure the National Health Service created in 1948.

Local health centres – such as those already examined in FinsburyBermondseyand Woolwich  were an important element of this programme and would be models for primary healthcare in the new post-1948 service.

Walworth in 1946 from www.britainfromabove.org.uk. Image EAW000645 © English Heritage

Walworth in 1946 from http://www.britainfromabove.org.uk. Image EAW000645 © English Heritage

Southwark first came under Labour control in 1919 when the Party swept to victory in local elections across the country. In the same year, the Maternity and Child Welfare Act was passed.  The new Council took up the cause, investing, for example, in a municipal store to supply cost-price or free milk and medicines to expectant mothers.

Southwark Labour lost power in 1922. The Municipal Reformers – antagonistic towards anything that smacked of ‘municipal socialism’ and jealous guardians of the ratepayer’s purse – scaled down these efforts.

But 1934 saw Labour back in power and committed to further reform. A Public Health and Sanitary Committee was established, a ‘complete investigation of the public health problems of the borough’ set under way.  The Medical Office of Health, William Stott, was asked to specify the premises he needed to deliver local health services.

The Centre in 1937

The Centre illustrated in 1937 with white stone parapets now disappeared

The result? Three years later, Southwark was ‘the first borough to have the whole of its health services in one building’ – a building which Councillor Gillian, the chair of the Committee, claimed ‘beats Harley Street’.(1)

The Council took the view, Gillian stated,  that :(2)

Cllr AJ Gillian

when the health of the people, and particularly the poorer classes of the population, is involved, only the best equipment and the most modern scientific devices would suffice.

The Walworth Clinic, built at a cost of £50,000, would be  in form and content a practical fulfilment of these principles.

The building itself, designed by Percy Smart, still has a strong presence on Walworth Road.  Architecturally, according to English Heritage who listed it Grade II in 2010, it’s notable for its ‘strong massing, brick elevations, and jazzy details…a hybrid of Modern Movement and Art Deco styles’.

The Lancet was complimentary: (4)

The borough council have wisely decided that the building shall have a pleasing appearance and by the brightness of its interior give a cheery welcome, so that the inhabitants may be encouraged to make full use of an institution devoted to the improvement of their health.

As shown in the opening programme

Statuary group as shown in the opening programme

Easily missed but powerful when viewed is the statuary group, by an unknown sculptor, at the top of the building. A woman and three children of varying ages, the figures are both allegorical (the woman is holding the healing rod of the Greek god Aesculapius) and recognisably ‘real’ with their modern hairstyles and the child’s doll. These were: (3)

Statuary groupdesigned to symbolise the functions of the new building with relation to family health – motherhood, various stages of childhood and the spirit of healing.

But if these externals were important – and they were for the combination of dignity and accessibility they offered to the priority of the people’s health – you can feel from the contemporary descriptions that it’s the facilities and equipment that really excited the professionals.

The Centre today

The Centre today

The side and rear of the building from Larcom Street

The side and rear of the building from Larcom Street

Southwark, in the best form of one-upmanship, listed its innovations – the ‘first maternity department in the country to have an illuminated colposcope’ (you can look it up), the first to install an X-Ray department, and the only borough to have a ‘complete full-time chemical and bacteriological laboratory’.  The building was air-conditioned too.

Artificial Sunlight and Radiant Heat Clinic

Artificial Sunlight and Radiant Heat Clinic

X-Ray clinic

X-Ray clinic

The Centre, the Council stated, marked ‘a further great step’ towards its goal – ‘the betterment of the health of the people of Southwark generally’.

That meant administrative offices and qualified personnel (including a ‘Lady Sanitary Inspector’ and ‘Lady Assistant Medical Officers’) too as well as the vital front-line services – a dispensary, a TB clinic and solarium, a dental clinic, regular maternity and child welfare clinics, of course, and a weekly clinic for women over 45 ‘subject to illness and disease peculiar to this age period’.

P1010790The basement contained a ‘Tuberculosis Handicraft Centre’ where unemployed TB sufferers could learn craft skills which might lead to employment or might, at least, provide a useful hobby.

Rheumatic clinics and breast-feeding clinics were planned for the future.

And the Centre was only part of a programme which the Council understood quite clearly as a comprehensive assault on poverty and its causes. When rats overran one part of Southwark, the Council built a new sewerage system, costing £70,000. Opened just three months after the health centre, it too aimed to raise ‘the health of the people’.

Whereas Southwark once had the highest death rate in London and one sixth of its houses had been declared unfit for human habitation, Councillor Gillian could assert in 1937 that: (5)

Coat of ArmsThis two-fold evil was being resolutely dealt with …Slums were being cleared, overcrowding was being overcome by new housing plans and Southwark was now one of the healthiest boroughs of London.

Over seventy-years later, the Elephant and Castle down the road is being redeveloped again and the centre itself looks slightly forlorn. There’s still an NHS clinic on the Larcom Street side but, as the signs in the contemporary photograph indicate, the building is to be let as office space. It’s a sad decline for a building which started with such bold and practical ideals.

In fact, the Walworth Clinic was a model superseded by the NHS a little over ten years after its opening.  There were plans for local health centres – based on these London examples – in the original NHS blueprint but the 162 envisaged, serving population centres of 20,000, were implemented only sporadically .

There was a loss here of democratic initiative, impetus and control that might have served the NHS well.  No-one would wish a return to the haphazard localism of the pre-NHS era but reforming and ambitious councils represented and practised the ideal of a community’s responsibility to safeguard and support its sick and vulnerable. The Walworth Clinic reminds us of that.

Sources

(1) Quoted in the Daily Telegraph, 17 September 1937 and South London Press, 1 October 1937, respectively

(2) Programme of the Opening of the New Health Services Department by the Worshipful Mayor of Southwark (Cllr CJ Mills) on Saturday September 25th 1937

(3) Programme of the Opening of the New Health Services Department…

(4) The Lancet , October 2 1937

(5) The Times, September 27 1937

Other detail and analysis comes from Esyllt Jones, ‘Nothing Too Good for the People: Local Labour and London’s Interwar Health Centre Movement, Social History of Medicine, vol 25, no.1 , February 2012.

The historic images come from the superb collection of photographs held by the Southwark Local History Library and Archive.

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As the UK moves to having four distinctive health care systems as a result of devolution, the role of local councillors in relation to health matters becomes less uniform. For example, unlike Wales, where health and local government bodies have been coterminous since 1974, England remains a patchwork quilt of overlapping health and local government bodies which is made worse by the ever increasing privatisation of both health and local authority services.

This short article captures some common issues about which councillors across the UK might want to think. Topics covered include: scrutiny and public consultations, shaping integrated systems, and public health.

Scrutiny and Public Consultations

In all four administrations local government can play a key role in holding the NHS to account, both by standing arrangements for Scrutiny and by taking a leading role in testing any proposals for service change which the NHS might put forward. The machinery for doing this varies – especially in England where market –style arrangements are increasingly used to govern the relationship between “commissioning” and “providing” functions  and where the public health function is now placed firmly in the local authority domain.

In England the Health Scrutiny Regulations 2013 are intended to give local areas flexibility and freedom to shape the scrutiny role of Health and Well being Boards as best fits local circumstances – including the option to establish topic – specific sub committees.

Scrutiny

Local authority scrutiny of selected health activities – based firmly on its democratic mandate for local leadership – should be built into the annual scrutiny programme. The regulations stress that local authorities are able to scrutinise three aspects: how health care services are planned, how they are provided, and how they are operated locally.  Local circumstances will shape some of the topics but councillors might want to might include at least one area of scrutiny work from each of the following categories.

  • The robustness of local arrangements between primary, social care and secondary care aimed at preventing  crisis referrals (and inappropriate admission) to acute hospitals
  • How well linked are health and local government planning functions for agreeing “need” and “demand” for the decade ahead in all parts of the Council’s  area (down to ward level)  – and the crafting of shared responses to such need.
  • How continuity of health care is ensured for looked after children leaving care.
  • How well local providers perform across a range of performance measures – including clinical performance and managerial / financial performance.

Public consultations

It seems inevitable that the NHS will continue to undertake public consultations on service change as austerity bites and increased attention is paid to existing service defects. Local councillors have a key role in all public consultations. They can:

  • Ensure key community interests are alerted as soon as news of impending consultations is known
  • Work hard, at an early stage, to try to shape the nature and language of the proposals so that the issues are written about in a way that ordinary people can see through what is proposed.
  • Ensure that the “Gunning  principles” on consultation are followed – for example, is it clear what the issue is about upon which views are sought; has sufficient information been provided; can it be seen that the decision makers are taking all comments seriously?
  • Use council resources (officer time to probe papers, meeting rooms for pubic sessions, generate publicity etc) to alert the public to the issues being  raised and to provide informed arenas to which health officials can come and have their proposals examined.

Shaping integrated care systems

Too often local councillors take little notice of what officers of health and local authorities are doing when it comes to trying to improve the co-ordination or integration of care offered by them both. Whether in the care of elderly, younger disabled, or mentally ill people, or in distinct services such as those relating to substance misuse and eating disorders, interest in, and leadership of, the better integration of services is sometimes lacking at elected member level.

Yet there are key issues upon which elected members could make a difference. For example, is the Council an outward looking one that sets the pace for its key partners, or does it shy away from partnership work? Does it put the protection of its budgets first or is it willing to experiment with joint funding and pooled budget methods? What about joint appointments of senior staff, with the freedom to switch or blend local authority and health cash and craft teams of people from both bodies? How well do information systems support the planning of locally relevant services, or report on their delivery of care? How often does the full Council debate such matters in public meetings?

Public Health

The public health function brings powerful tools to an understanding of health issues – whether this sits within local government as in England, or within the NHS.

Wherever it is located organisationally, elected councillors should take an interest in its work across a number of dimensions. Some of these are briefly described below.

Health Status Reporting

The production of useful and intelligible data on the health status of complete local authority areas, and smaller areas within them, should be a routine task of the public health function – and should be used regularly by Local Authorities. Housing, education and environmental health tasks of local government all play a part in ensuring good and improving levels of public health. Economic data should also feature as there is some evidence that health status and differentials in income in localities are linked.

Mortality and morbidity data

Local councils should have an understanding of what are the main killers are in its area, and what are the main causes of major illness that impact adversely on the quality of life. While the major causes of death are likely to be cancer and heart disease, the causes of significant lost years of life may extend to include suicide, accidents, violence and avoidable childhood diseases.

Morbidity data will show how such conditions as depression, diabetes, substance misuse, chest disease, and physical disabilities  impact upon different social groups in different localities.

Equity and access

Linked to such data is the notion of equity and access – equity of outcomes and health indicators and access to health (and other) services. For example immunisation rates and attendance at screening services vary. Average life expectancy in many local authority areas will vary by 5 or more years between the healthiest and least healthy wards.

The council as a public health body

Despite the changes in 1974 when local government lost key health functions such as health visitors and medical officers of health, Local authorities have always had a key public health role beyond the narrow confines of Environmental Health. It is a key partner. Councillors should ensure they have machinery for assessing the nature and quality of their partnership arrangements.

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Public funds and commissioning need to be in the hands of those who are elected, accountable and representative

This article first appeared in the Health Service Journal.

There are three main reasons why local authorities ought to also have the strategic responsibility for the planning and commissioning of health services:

  • it brings the democratic accountability we rely on for (almost all) other public services;
  • it allows total public funds for an area to be allocated to best overall advantage and for strategic investment decisions − population based decisions; and
  • it allows for economies of scale − especially in management, administration and support functions

Arguably, there is one further reason: local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning). They are many years ahead on the “best value” journey. They are also far better at resisting vested interests and conflicts of interest: it’s one reason why we have democracy.

Only those who are accountable through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set. For most of the lifetime of the NHS, public money flowed to the providers of healthcare based on history − just roll over what was used the previous year plus or minus a bit. Long waits and restrictions on access balanced the books. There was no planning, no sense of public involvement in decision making and no proper measures of value for money.

Two decades of commissioning by various flavours of NHS bodies has not managed to change things much, and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care. The biggest inefficiencies in our NHS are arguably no longer in providers being inefficient in delivery, though they are, it is that we allocate spending on the wrong things.

A new set-up

Because the funding stream for health is separate, there are fewer incentives to cooperate, and even some perverse incentives to compete for funding. If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another, which should be a ludicrous idea but it has a twisted logic in the current fragmented set-up.

So does change require a reorganisation?

The reality is that in many parts of the country, the local authorities and the NHS are already working together − and where it works best is where the local relationships are good. That can be built on and encouraged, but each locality has to be left to find its own way.

We could start by a few simple measures:

  • Give health and wellbeing boards the responsibility to sign off clinical commissioning groups’ commissioning plans, which currently rests with NHS England, and to monitor delivery.
  • Make a joint commissioning framework and policies mandatory as with the joint strategic needs assessment and the area wellbeing strategy.
  • Extend the scope of needs assessment to embrace resources available to meet needs and extend also to housing and education.
  • Strengthen governance of Clinical Commissioning Groups by having non-executive directors to prevent conflicts of interest, so that all of primary care can be brought into their local remit, which currently with NHS England.
  • Set financial limits, for example £5m, above which agreement from the local authority would be required.

And in a longer timeframe:

  • make CCGs and local authorities coterminous (many CCGs  are smaller than local authorities);
  • integrate commissioning and other support functions; and
  • pool the whole budgets.

None of this requires any major whole system reorganisation. Nor should it be done through top-down imposition; each locality should be left to find its own way at its own pace, so long as it delivered improving and better integrated care. CCGs can retain most of their role through having delegated responsibility.

We have a clear choice. We leave major decisions about how our public funds are allocated to those who are unelected, unaccountable and unrepresentative − and who have a track record of failure. Or we trust democracy, where at least we can find out what is going on and can get rid of those that fail. Democracy is far from perfect, but it is better than the alternatives.

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David Colin-Thome, Independent Healthcare Consultant and Visiting Professor, Manchester Business School, Manchester University, UK and School of Health, University of Durham

Brian Fisher, GP and Patient and Public Involvement Lead, NHS Alliance

Key message

If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice and community development.

Why this matters to us

When I (Brian) started GP practice in 1976, I found a community-development programme a few steps from the health centre in south-east London. It was founded on principles of social justice and values of co-operation and challenging power. It changed my life (and I married the community worker…) and I have tried to put these values into operation across the NHS ever since.

When I (David) began GP practice in 1971 I was greatly influenced by Dr Julian Tudor Hart and Dr Geoffrey Marsh who, as GPs, focused on the individual and the population of patients. Later, I was influenced by my friend Professor John Ashton as we explored the GP practice as a public health organisation, and further shaped by my work as  a local councillor.

Key message

If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice  and community development.

Health and Wellbeing Boards are one of the innovations in the Health and Social Care Act of 2012. They could herald a long overdue new public health by harnessing community activity such as asset-based community development.  Health and Wellbeing Boards are intended to span the worlds of public health and primary care.

The Role of Health and Well-being Boards

Each top tier and unitary authority will have its own health and wellbeing board. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

  • Health and wellbeing boards will have strategic influence over commissioning decisions across health, public health and social care, integrating services.
  • Boards will involve democratically elected representatives and patient representatives in commissioning decisions alongside commissioners across health and social care.
  • Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community.
  • Through undertaking the Joint Strategic Needs Assessment (JSNA), the board will drive local commissioning of health care, social care and public health, bringing in other services such as housing and education provision.

R.H.Tawney said: ‘The poor have remained beloved by the Gods being afforded excellent opportunities for dying young’.  This remains a truth today despite the huge improvements in the public’s health and in healthcare. These improvements have disproportionately benefitted the more advantaged.  Narrowing these inequalities should be a priority of Health and Wellbeing Boards. Can they deliver this when so many public health policies of the past have not? We argue that they can, and they must. To do so they must complement the present public health approach that is concerned with discrete interventions targeted at individuals, with on-going interventions that help whole communities and families to help themselves.

General practice has always had a population responsibility (the registered list) as well as a responsibility to individual patients. These twin responsibilities lie at the heart of what it means to be ‘family and community-oriented’ – concerned not only with treating the diseases that a patient has, but also recognising the impact of their social context – family relationships, jobs, crime and so on. Indeed, this is one of the main reasons why  decentralised generalist healthcare systems are more effective than centralised specialist-led systems. In the words of Berwick:  “general practice and primary care is the soul of a proper, community orientated, health-preserving care system’[ii]. In the words of Starfield: “The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus[iii]

Clinical Commissioning Groups  now have their hands on the reins of the NHS. This presents an opportunity to meaningfully span the general practice role of personal care and public health in collaboration with their local authorities through Health and Wellbeing Boards. General medical practices are statutory members of CCGs and have to work together to achieve the aims of Clinical Commissioning Groups to reduce costs and retain quality. As has been described in recent papers in LJPC, it is becoming increasingly common for clusters of 10-20 practices who serve populations of about 50,000 to come together to develop collaborative practice – to share the load of overwhelming demands, for mutual support, and for improved care. Different places have called them different things – ‘Local Health Communities’, ‘Health Networks’, ‘Cells’ and ‘Hubs’.

These new clusters of general practice could provide a shared space for collaboration between public health and primary care. In these spaces multiple agencies could work together to provide in our cities and towns what pioneers like Julian Tudor Hart in South Wales[iv] and achieved in small communities – improving whole community capacity and resilience as well as personal medical care. They could translate to the 21st century the vision of Sidney Kark’s ‘community oriented primary care[v] and Ashton’s ‘New Public Health’[vi],

Health and Well-Being Boards  could make this happen, by ensuring that general practice and community services plan and act in concert with public health, local authorities, schools, voluntary groups and many other organisations, to synchronise their efforts for health improvement. Conventional individually-focused approaches to health promotion (e.g. smoking cessation, healthy eating and physical activity) could be complemented with social approaches that harness the energy in communities (termed ‘asset-based community development)[vii].  This approach helps people to help themselves – more effective than imposed solutions. As Kretzmann says: “healthy communities have never been built upon their deficiencies but have always depended upon mobilising the capacities and assets of people and place[viii]. It means recognising that health is more than the sum of their medical diseases, and includes a sense of coherence that Antonovski calls salutogenesis[ix] and MacIntyre calls Narrative Unity[x].

In this paper we revisit the evidence that a social approach to health improvement is effective at improving health and that it is cost effective. From this we suggest what Health and Wellbeing Boards can do to shape a winning course.

A community development approach improves health

Community development builds confidence to act for health improvements. For example, community development work on the Beacon estate in Cornwall showed sustained improvements – when the community realised that they could make a difference by working together, their motivation to act increased and they caused sustained improvements in housing, education, health and crime[xi]. Similar results have been seen in Balsall Health[xii].

The key link is that community development extends and strengthens social networks. These are the links between people that shape their sense of identity – making them feel that they belong and capable of making an impact. Social networks are formed in thousands of ways everyday brief encounters – in pubs and shops, clubs and schools for example.  Social networks are good. A meta-analysis of data across 308,849 individuals, followed for an average of 7.5 years shows a 50 % increased likelihood of survival for people with stronger social relationships.  This is consistent across age, sex, cause of death and is comparable with risks such as smoking, alcohol, Body Mass Index and physical activity[xiii].

Social networks and social participation also protect against cognitive decline and are associated with reduced morbidity and mortality[xiv].  Low levels of social integration, and loneliness significantly increase mortality[xv].  Social networks are weaker in more deprived areas and poor social participation is associated with mental ill health[xvi].  Improving social networking and social relationships reduces the risk of depression[xvii].

Those areas with stronger social networks experience less crime[xviii]   while enhancing employment and employability[xix].  Social cohesion and informal social control predict a community’s ability to come together and act in its own best interests and is derived, in part, from participation in local associations or organizations[xx].

There are a variety of models of different kinds of community development to examine, many of which have improved healthcare services. For example the “Linkage plus” programme developed and deepened social networks for older people while redesigning health services with their participation. Significant improvements in health and independence resulted[xxi].

Two examples of what has become to be termed ‘Asset Based Community Development’:

The Health Empowerment Leverage Project, HELP

HELP  focuses on the creation of a long-term problem-solving neighbourhood partnership between residents and front-line services from health and other agencies. The partnership is led by residents but generates parallel action and learning amongst agency staff enhancing the development of confidence, skills and co-operation and creating a cumulative momentum so that such developments are self-renewing so the whole atmosphere of the neighbourhood becomes more positive.

HELP adopted a method known as ‘C2’,   which displayed exceptional success over 15 years across 6 deprived rural and urban estates.  A review of the longer term effects of a C2 project run on the Beacon Estate in Penwerris, Cornwall found improvements between 1995 and 2000 in education, health, employment and crime.18

HELP has developed an approach that can assist Clinical Commissioning Groups and Health and Wellbeing Boards to assess the social capital of their communities and track changes that have taken place as a result of intervention.

Connected Care in eleven sites since 2006.

The Connected Care project,  part of the organisation Turning Point, set out to build on existing social capital and resilience to improve health and social care outcomes for local people in Owton ward in Hartlepool.

Community Researchers were recruited from the local community and supported by Turning Point and local agencies. Two hundred and fifty one local residents participated in an audit via one to one interviews, focus groups and a community “have your say” event.

The results of the audit informed the development of the Connected Care service that is delivered through a local community social enterprise, incorporated as a Community Interest Company. The service includes navigators, a debt and benefits advice service, support for older people to stay in their own homes for longer, supported housing for young people as well as a gardening and handyman service. It also includes a time bank to utilise the skills of local residents and co-ordinate volunteering between local people. Connected Care is now managing 32 flats in Glamis Walk that are owned by Accent Foundation who have now commissioned Connected Care to manage the whole estate.

Connected Care is being rolled out across Hartlepool building on the service delivered in Owton ward and community research activity across the town over the last 18 months.

The programme in Hartlepool has expanded from 100 people receiving support to over 500 people benefiting from the range of services – including benefits and welfare advice, luncheon clubs, social activities, gardening and handyman services, and meals on wheels. This service is expecting to triple again the number of people in the SAILS programme over the next year. On the back of this expansion the Council has awarded Connected Care the contract to provide luncheon clubs and reablement support for elderly people leaving hospital.

Cost-benefit of Community Development Initiatives

The evidence above shows that community empowerment improves health, and there are good reasons why general practice should contribute to leadership of such community empowerment; also the contemporary clustering of general practices into geographic areas provides a new practical shared space for it to happen. Surely Health and Wellbeing Boards and Clinical Commissioning Groups must therefore ensure that it happens.

But there is one important other piece of evidence – is it cost-effective?

Studies show that community empowerment is cost-effective, not merely in deprived areas but in all economic climates[1]. When people in an area take charge of their destiny, they can better contribute to the design of cost-effective and humane services that improve quality and contain costs better than when they are unable to contribute.  Making resources available to address the association between poor health and poor social networks and break the cycle of deprivation has been shown to decrease health care costs[2].

Social Return on Investment19 is a social value approach to measuring an economic return on investment. It has been used to track the cost benefit of a community development worker in four local authorities, identifying, supporting and nurturing volunteers within their areas to take part in local groups and activities.

An investment of £233,655 in community development activity was found to have created approximately £3.5 million in social return, a return of 15:1. The time invested by members of the community in running various groups and activities represented almost £6 of value for every £1 invested by a local authority.

Lomas shows that harnessing social networks has an effect comparable to bio-medical interventions. He estimates for every 1000 people exposed to each “intervention” per year

  • Social cohesion and networks of associations would prevent 2.9 fatal heart attacks
  • Medical care and cholesterol-lowering drugs would prevent 4.0 fatal heart attacks in screened males

HELP was asked by the Department of Health to explore the cost-benefit of community development . Examining the HELP interventions in three neighbourhoods across England,it was estimated that serious medical events would be reduced by 5% per year – an NHS saving of £558,714 over three years on depression, obesity, cardio vascular disease. This is as a result of local interventions such as exercise groups, dietary interventions and deepening of social networks.  This is a return of 1:3.8 on a £145,000 investment in community development over the three years.  Adding savings produced by reductions in crime and anti-social  behaviour would produce a further saving of £96,448 a year per neighbourhood using directly age standardised mortality rates per 100,000  £868,032 across the 20% most disadvantaged neighbourhoods of a local authority and £130m across England. This represents a return of 1:9.

What should Health and Wellbeing Boards Do?

It is understandable why there has been so little general practice leadership of community empowerment – medical training that emphasises the treatment of discrete diseases and the science of collaboration and empowerment is largely absent from formative and continuous medical education. Health and Wellbeing Boards must act to reverse this, firstly at the post-graduate level, working with Local Education Training Boards to develop skills to lead this in the new clusters of general practices.

It is understandable why there has been so little collaboration between general practice and public health practitioners to lead community empowerment – general practices have operated in isolation to deal with patients on a one-to-one basis. Previously attempt to systematically build community resilience and social cohesion have only been realistic in small communities where the shared boundaries are given by nature. In larger areas the absence of shared boundaries fragments collaborative initiatives. Health and Wellbeing Boards must act to consolidate these new clusters of practices as a shared developmental space where local authorities, public health business and third sector organisations can contribute to a New Public Health.

It is understandable why there is not more evidence of the huge untapped potential of community empowerment to improve health. Databases in the NHS are focussed on individuals with individual diseases.  Health and Wellbeing Boards must ensure that Clinical Support Units routinely gather data of the effect of these clusters on things like unscheduled admissions to hospital, place of care for those who are dying, and a breadth of other indices that will be affected by the large number of small acts of kindness that happen in empowered communities. They must provide reports of these data on a regular (monthly) basis so local people can witness the effects of their actions.

Health and Wellbeing Boards should also support pilot projects within these clusters, and create mechanisms for results to be fed back to Clinical Commissioning Groups so others can learn and change. Health and Wellbeing Boards should encourage such long-term capacity-creating interventions as an antidote to the usual old-fashioned projects that have short-term focus. They should work with universities to support evaluation of these initiatives.

The literature about Asset Based Community Development is particularly worth reviewing. This involves residents identifying local skills and experience, then discovering what they care enough about to change, then creating mechanisms to act together to achieve those goals. HELP and Connected Care use this approach.

If Health and Wellbeing Boards perceive their roles narrowly they will chart a traditional course with two or three key priorities focused on (probably medically-perceived) priorities. And they will fail. But if they claim a wider role (and they should), they could position themselves as enablers of a new public health that provides the training, the conditions and the evidence that community empowerment produces better health at lower cost.

References


[1] Knack S. Social Capital, Growth and Poverty; A Survey of Cross-Country Evidence. Social Capital Initiative, Working Paper No. 7, Washington, D.C.: World Bank. 1999

[2] Fair Society, Healthy Lives Strategic Review of Health Inequalities in England post 2010 p139 The Marmot Review February 2010 © The Marmot Review ISBN 978–0–9564870–0–1 Xiix

[ii] Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838

[iii] Starfield B, Shi L, Macinko J. (2009) Contribution of primary health care to health systems … quality of care in England. N Engl J Med. 361(4): 368–78

[iv] Hart J. A New Kind of Doctor. (1989) Merlin Press

[v] Communityoriented primary care: the legacy of Sidney Kark. American Journal of Public Health. 83(7):946-7, 1993 Jul. Gillanders WR)

[vi] Ashton J, Seymour H. The New Public Health. Milton Keynes:  OUP, 1988

[vii] Morgan M. & Ziglio.  Revitalising the public health evidence base: an asset model in Morgan & Ziglio (Eds) Health Assets in a Global Context: Theory, Methods, Action, Springer. 2010.

[viii]  Kretzman and McKnight.  Building Communities from the inside out. 1993.

[ix] Antonovsky, A. Unraveling The Mystery of Health – How People Manage Stress and Stay Well, San Francisco: Jossey-Bass Publishers, 1987.

[x] MacIntyre A. After Virtue. London: Duckworth, 2000

[xi] Developing sustainable social capital in Cornwall: a community partnership for health and well-being (The Falmouth Beacon Project) By Hazel Stuteley O.B.E. and

Claire Cohen Cornwall Business School, 2004

[xii] Atkinson D. Civil Renewal . Brewin Books 2004 ISBN1 85858 267 9

[xiii] Holt-Lunstadt, Smith, Bradley Layton Social relationships and mortality risk: a meta-analytic review..Plos Medicine July 2010, Vol 7, Issue 7.

[xiv] Jenkins R, Meltzer H, Jones P, Brugha, T and Bebbington, P. Mental Health and Ill Health Challenge. London:Foresight. 2008.

[xv] Bennett K. 2002. Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 31: 165-168.

[xvi] Berkman LF and Kawachi I (2000) ‘A historical framework for social epidemiology’ in Berkman LF and Kawachi I (Eds.) Social epidemiology. Oxford: Oxford University

[xvii] 9 Morgan E and Swann C. Social capital for health: Issues of definition, measurement and links to health. London: Health Development Agency. 2004

[xviii] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

[xix] Clark P and Dawson S. Jobs and the Urban Poor. Washington, D.C.: Aspen Institute. 1995

[xx] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

[xxi] Willis M and Dalziel R. LinkAge Plus: Capacity building – enabling and empowering older people as independent and active citizens. Department for Work and Pensions Research Report No 571 2009

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In the context of whole person we need health services to be aligned with all the other public services. We need to focus on tackling the social determinants of poor health, investing in better health, and only the public service approach can do that.  Only local authorities can be the focal point for bringing public services together.  Only those who are accountable to us through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set.

But, the antipathy that exists within the health service to local government is matched only by the reluctance of most local authorities, already coping with austerity, to get involved in health services which are seen as shambolic.

Whatever method is used to plan or commission should take into account all of the public services and the total of resources available.  It is incidentally an argument against ring fencing of funding for separate services.

There are three reasons why local authorities ought to also have the strategic responsibility for the planning/commissioning of health services:-

  • it brings the democratic accountability we rely on for (most) other public services
  • it allows for total public funds for an area to be allocated to best overall advantage and for strategic investment decisions – population based decisions
  • it allows for economies of scale – especially in management, administration and support functions

And arguably there is one further reason:-

  • Local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning) – they are many years ahead on the “best value” journey.  They are also far better at resisting vested interests and conflicts of interest – its one reason why we have democracy.

Alongside the basic ideological case for democracy this is about how we get the greatest value from public funds. For most of the lifetime of our NHS public money flowed to the “providers” of healthcare based on history – just roll over what was used the previous year plus a bit. Long waits and restrictions on access balanced the books.  There was no planning, no sense of public involvement in decision making and no measures of value for money.  Two decades of commissioning by various flavours of NHS bodies have not managed to change things much and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care – care closer to home.  The biggest inefficiencies in our NHS are arguably no longer in providers being “inefficient” in delivery (although they are) – it is that we allocate spending on the wrong things.

Responsibility and funding for social care is with local authorities and subject to means testing in contrast to free “health” care.  Sixty years ago this did not appear to matter much, now the fact that our care is split between two armed camps that do their best not to communicate and have huge cultural differences matters a lot.  Not to mention the issues around totally inadequate funding for social care impacting on health.

Finally we can note that because funding streams are separate there are fewer incentives to cooperate, and even some perverse incentives to compete for funding.  If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another – which should be a ludicrous idea but which has a twisted logic in the current fragmented set up.

So does change require a reorganisation?

The reality is that in many parts of the country the local authorities and the NHS are already working together – and where it works best is where the local relationships are good, informal arrangements are made and they ignore the complexities of governance and just do it.  That can be built on and encouraged but each locality has to be left to find its own way.

We could start by a few simple measures:-

  • give Health and Wellbeing Boards the responsibility to sign off Clinical Commissioning Group plans (now rests with NHS England) – and to monitor delivery
  • and sign off on social care budgets and commissioning plans

(both plans must explain how they took the other into account)

  • make a joint commissioning framework (and policies) mandatory as with Joint Strategic Needs Assessment and the area Wellbeing Strategy
  • strengthen governance of CCGs by having non executive directors to prevent conflicts of interest so that all of primary care (including GPs) can be brought into their local remit (currently with NHS England)
  • set financial limits above which agreement from the LA would be required (~£5m)

and in a longer time frame

  • make CCGs and LAs coterminous (many CCGs are smaller than their  Local Authority)
  • integrate commissioning and other support functions
  • pool the whole budgets.

None of that requires any major whole system reorganisation.  And it should not be done through top down imposition; each locality should be left to find its own way at its own pace so long as it delivered improving and better integrated care.

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I have already commented on the trends and costs of the growing burden of health inequalities in the UK and what this means for growing numbers of the population in particular disadvantaged communities.

The recent report,  just published from Prof John Hills team at the LSE on wealth inequalities trends, rebased from official stats, also confirms this widening disparity between those able to leave wealth, in whatever form, and those with no wealth.

However if Austerity continues in this “hair shirt” addiction then the consequences will become ever more real to many more people, not just those at the bottom end but increasingly up the economic ladder in real terms as well. This will cause more pressures on families, communities and wider as well as services, resources and those who seek to be responded to.

So why is this recession different to others?

There are four key differences.

Firstly a diminished safety net for the unemployed. Median earnings benefits and tax credits have fallen in real terms so the outlook for some years to come, amongst a significant part of the population and in pressured areas, is long term.

Secondly new unemployment co-exists with significant structural worklessness in the form of long term sickness absence and disability pension receipt. Govt has sought to seek changes to disability support and pension receipt.

Thirdly the nature of work has changed within Britain during the last 20 years. As we have seen with a low industrial workforce, increases in services but more uncertainty in employment with no hours working, short time working and other peculiarities. So low paid marginal and uncertain employment is more likely for low wage earners than not. All this leads to more negative health impact of unemployment and indeed employment.

Lastly the labour market is becoming more feminised and gender roles are shifting again because of the ability of women mainly to work for low pay and not engaged with their work conditions. Ironically all this at the same time as the Govt currently has hit the family and single women harder in support terms in the total social good aspect.

We cannot think that health is a silo subject on its own but within the Public Health remit particularly, and in Social Care and the NHS, it is a key aspect as is the social well being of the community.

Part of the neo-liberalised agenda is to compensate for these upward pressures by negative changes to financial support, changes to rules which become discriminatory and changes to support inversely to those communities which need it more.

This approach affects not only individuals but communities and their resilience. Social support, as we are seeing, vulnerable groups being marginalised, whether social support or supported housing or for the disabled, and therefore their health and well being suffers.

So if health becomes an issue and health inequalities effect worsens then how should we move forward?

From an economics viewpoint, as even the IMF have stated, in a much different way to what is being implemented now. They have repeated this message in rapid succession surprisingly for such a conservative approach body.

Social good and economic good are compatible not separate as those siren voices would have us believe.

Paul Krugman’s thesis, the Nobel award economist backed up by a host of other key left economists, such as Robert Reich, is that by attacking the social good and reducing the level of real disposable income you weaken overall position in the economy much worse.

So in the UK we have had stagnation and indifferent performance. Cuts in public spending, as a Joseph Rowntree Foundation (JRF) report concluded, found unsurprisingly are affecting not only long term health and well being (from libraries to adult social care etc.) but the very nature of the cuts or austerity those who need those services their health.

So we have widening health inequalities, fuel poverty and absolute poverty, food banks, reduction in pension values, an increase in mental health, more domestic violence, education reductions which affect pupils in disadvantaged areas not being able to access higher education and much more.

Women and single parent families as well as ethnic minorities are particularly hard hit and when we get into young people the levels of youth unemployment, although not the levels of Greece or Spain are over a million.

The effects on physical and mental states which are well known within the work of Marmot over cardiovascular disease, mental health which this government seeks to marginalise or ignore, health behaviours leading to drugs ( recreational and depressives) and alcohol and of course more morbidity and possibly suicides as well. 

So instead of austerity, reduction in the mean level of salaries and wages, curtailment of support services and benefits which hit the poorest harder, but not just the poorest either, we should we embarking on a different strategy.

That strategy needs to be based round a growth strategy which will improve well being outlook, tackle health inequalities and pressures in deprived communities. That will activate the economy put people into work and tackle the debt as from a positive position. 

It will not need quantative easing either as more positive generation of income will stop the need to add to the £375 billion of artificial stimulus which already has been actioned to an increasingly diminishing effect except to the debt level.

Increase sin salaries/wages, benefits will help and assist at the bottom end so instead of food banks need people will have enough disposal income to purchase in shops.

Getting people back to work will increase well being, as I have stated, but it will do much more than that as it will create jobs, stimulate a positive benefit to all and lower health service and other needs pressures for junk cheap foods.  

It really is a no brainer but neo liberalists will not see that as a positive intervention.

As we come up to Control Period 5 (UK Treasury Expenditure profile allocation. PSBR) and the statement of another £11.5 billion reductions for 13/14 provision potential, including even more to Local Government and key services, benefits and much more that the communities and its people rely on.

Such an approach will also have far reaching consequences; not only for Public Health, but Social Care and the NHS which it is already doing so.

As Bill Clinton said “it’s the Economy stupid”

That is certainly correct but unless we have the right global strategy and UK strategy it’s also the health and well being of its people stupid!

The longer we leave positive intervention the worse the scenario gets for increasingly more and more people.

Cllr Mike Roberts v/chair SHA (Local Government) May 2013

NB.      Wealth on the UK: Distribution, accumulation and policy (Prof John Hill etc. Centre for Analysis of Social Exclusion)

2.     Liverpool Observatory Report February 2012

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