http://www.nwda.co.uk/pdf/pub_health by Northwest Regional Development Agency

Report of a conference

Health & regeneration developing investment for health in the northwest region

16 September 2002

The Northwest Development Agency manages all operations from its Headquarters at: PO Box 37 Renaissance House Centre Park Warrington Cheshire WA1 1XB Tel: +44 (0)1925 400 100 Fax: +44 (0)1925 400 400 e-mail: Information@nwda.co.uk

In addition, there are five area offices for local implementation activities as follows: Greater Manchester Giants Basin Potato Wharf Castlefield Manchester M3 4NB Tel: +44 (0)161 817 7400 Fax: +44 (0)161 831 7051

Cumbria Gillan Way Penrith 40 Business Park Penrith Cumbria CA11 9BP Tel: +44 (0)1768 867 294 Fax: +44 (0)1768 895 477

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www.nwda.co.uk www.englandsnorthwest.com

KADM 04/03/17368

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Leverage capital and the Health Dividend in England . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dominic Harrison Associate Director, Health Development Agency England

Conference report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Regional economic and health investment strategies – closer alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Mike Shields Chief Executive, Northwest Development Agency Joining forces to invest in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Steve Machin Chief Executive, Northwest Regional Assembly Claiming the health dividend – the evidence and the national picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Jeff French Executive Director, Health Development Agency Tackling health inequalities through anti-poverty strategies and the role of the health services – recent experience from Ireland and Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Sara Burke Institute of Public Health in Ireland Where does ‘health’ come from? Changing the views of the workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Sue Antrobus Director, Royal College of Nursing Political Leadership Programme Rural health and regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Tony Potter Executive Director, North Cumbria Health Action Zone

Opportunities for change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 The NHS and food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Angela Towers Development officer, North West Food & Health Task Force The NHS and training, education and employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Nigel Burke Director of Education and Social Inclusion, Government Office North West Case studies: NHS capital projects . . . . . . . . . . . . . . . Merseyside and Cheshire Health Authority area Greater Manchester Health Authority area . . . . . Cumbria and Lancashire Health Authority area .

. . . .

27 28 30 31

Key messages from round table discussion groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Investing in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 John Ashton Regional Director of Public Health

Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Conference delegates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

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Introduction It is vital that we link health and regeneration if we are to use all opportunities to invest for better health for our people. The NHS has a massive capital investment plan that could add value to other regeneration activity in the area. The NHS is one of the biggest employers in Europe, and one of the biggest purchasers. Imagine how that could be harnessed to add value to other programmes and initiatives for social, economic and environmental development. If we can bend the vast programme of public expenditure to deliver health gains, imagine the increase in well-being and productivity. This is the report of a conference which brought together some of the key players in the North West who could make this happen. The conference was organised by the Northwest Development Agency in partnership with the Health Development Agency, the North West Regional Assembly, Government Office North West and the Department of Health and Social Care North West, and supported by New Start magazine. In the following pages you can find details of the presentations, and the responses of delegates. The conference came at an opportune time, a few months after the publication of Claiming the Health Dividend, a report from the Kingâ&#x20AC;&#x2122;s Fund which spells out how the benefits of NHS spending can be unlocked. On Page 7 you can find an introduction to the thinking behind this report, which informed much of the debate at the conference. The Northwest Development Agency is keen to build on the momentum generated by the conference, and the Update section shows what progress has been made since September. However, the linking of health and regeneration is not only an opportunity for the NHS. All sectors have a responsibility to look at how their spending impacts on health, and to ensure that the impact is positive. The new regional health framework, Investing in Health, spells this out in detail. I hope you find this conference report helpful in developing investment for health in the North West. Kath Reade Board Member, Northwest Development Agency Chair, Cumbria and Lancashire Health Authority

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Context

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Leverage capital and the Health Dividend in England Dominic Harrison Associate Director, Health Development Agency England In 1866 Florence Nightingale was asked to open the new Manchester Children’s Hospital. She refused, proffering a curt reply that could stand today as a summary of the principal strategic deficiency of the Department of Health’s NHS Plan. She wrote: ‘Building more children’s hospitals is not the proper remedy for infantile mortality and sickness – the true remedy lies in improving children’s homes.’ Despite much recent progress, Manchester still has one of the poorest housing stocks in Western Europe, and housing continues to make a significant contribution to admissions at the children’s hospital. Indeed, there is some evidence to suggest, as Florence Nightingale implied, that neither health care services nor indeed health promotion services make much difference to the health of populations. An authoritative World Bank Review in 1993 drew exactly that conclusion. They were unable to find any relationship anywhere in the world, between national spending on health services and the health of populations.1

Determinants of health are outside the NHS At the root of this problem is the uncomfortable fact that the prevention of disease and the promotion of the public’s health cannot be easily purchased as an ‘additive commodity’ – that is, something to be bought from health-directed expenditure, i.e. health care system (NHS) expenditure. The health of any population is an outcome of ‘emergent capacity’ arising from the integrated effects of health-related social, economic and cultural investment on individuals and communities. You can’t have unhealthy housing, work, schools, communities, prisons, transport systems and hospitals and then expect to buy some health later, by funding a health promotion programme or building a hospital. At a population level, health is a ‘social product’ not a commodity. This is not to say that health care services or hospitals are unimportant. For the relatively small percentage of the population who are ill at any one time, they may be crucial. But the overwhelming majority of the population are made ill or kept healthy in their families, communities, schools, and workplaces – long before they have contact with the health care system. Lack of investment in health development now, and lack of social intervention into ‘health risk conditions’, outside of the health sector, will certainly result in early, unjust and avoidable disease or death – just as much as any refusal to treat curable disease would do. Yet ‘Investment for Health’ is still seen as investment in health care services, and the observation of Florence Nightingale 135 years ago seems curiously difficult to translate into health sector policy. Fortunately however, recent seismic shifts in the organisation of public sector business and the consequent development of new governance systems have opened up space for a wider debate on system futures – with the implicit assumption that what is not required is just ‘more of the same’. One development in particular holds the prospect of addressing Florence Nightingale’s agenda – realising the ‘development capital’ of the NHS.

Leverage capital One of the most significant contributions of the health care sector to population health has yet to be recognised. This is the nascent economic and social ‘leverage capacity’ generated by the NHS’s institutional market dominance. The health care sector in the UK is responsible for sustainably generating over 9% of all jobs and is the largest employer at regional and national levels. At local government levels NHS employment as a percentage of all those employed can rise in some districts to 26%.

1 World Bank (1993) World Development Report: Investing in Health. World Development Indicators. New York. Oxford University Press

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Recent research has demonstrated that the NHS in London contributes 10% or £10 billion to the gross domestic product (GDP) of the region when the indirect effect of spending by health workers is taken into account.2 The total NHS spend (of cash) in the capital is £7billion, providing one of the most significant sources of employment in poorer areas and making the NHS a leading social and economic regeneration agent. Research in another NHS region demonstrates that a 3.2% increase in health spending increases labour payments in all sectors by 3.84%, which may lead to an increase in employment in the region of 66,841 jobs in all sectors including 3,241 jobs in the health sector. This confirms theoretical work undertaken by the World Health Organisation which suggests that increased health sector spending could give a six-fold return on investment3. With a total budget of about 7% of GDP nationally (an annual and sustainable £4.9 billion spend in the North West), the NHS is the largest UK employer and one of the largest single UK generators of waste, a major capital investor (in disadvantaged areas), user of water, food purchaser, land user, generator of transport use, generator of bank accounts, purchaser of facilities, training and education, research and development, user of cleaning, disinfectant materials, chemicals, paper, plastics etc and user of information technology. The potential for ‘leverage’ on all these issues – to ensure health protection and generate health development through purchasing, contracting and management mechanisms, is (almost) entirely unexploited. This poses serious public health challenges for the (non-clinical) management of the health care system – concerning equity, sustainability, social inclusion and health. A multinational company would have ‘sweated’ (realised) this hidden ‘leverage capital’ years ago. The NHS in England is just now realising that far from being outside of the reality it wishes to change to improve health, it may be sitting on one of the nation’s most under-utilised levers for health promoting change – its capacity to influence wider social systems through the marketplace.

The ‘health dividend’ The Department of Health publication Tackling Health Inequalities highlighted how the NHS as a major employer and business in virtually every locality had a role to play in tackling inequalities. In July 2002, the King’s Fund produced a report – Claiming the Health Dividend: Unlocking the benefits of NHS Spending – which demonstrated the potential for the NHS to become a good corporate citizen in the domains mentioned above.4 The agenda outlined in this report is the agenda of the September 2002 ‘Health and regeneration’ conference. The Health Development Agency is planning to map the capacity of the NHS to claim this health dividend, and develop health promotion and public health practice at all levels in which influence may be gained. If the public sector worked together on key leverage issues, a wide range of governmental policy objectives – on social inclusion, equity, sustainable development and health improvement – could be more rapidly achieved. What could be the impact on the Cumbrian economy after Foot and Mouth if all the schools, hospitals, social services and county and local government agencies together decided to ‘buy locally’? How could a similar alliance of public sector organisations affect leverage on the banking sector in relation to ‘financial exclusion’ in Merseyside? The key challenge will be whether the health sector in England can extend its institutional and bureaucratic capacity to re-align its investment and policy in estates, facilities, procurement, planning and finance to address its own mission.

2 Travers T, Glaister, S , Graham D (2000) Capital Asset: London’s healthy contribution to jobs and services. NHS Executive London 3 WHO (2001) European Perspectives on the Macroeconomics and Health Report’ WHO Euro. Copenhagen 4 www.kingsford.org.uk

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Conference report

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Regional economic and health investment strategies – closer alignment Mike Shields Chief Executive, Northwest Development Agency

Opportunities for change There are currently great opportunities at regional level to change things for the better, as we finalise three key strategies – the Review of Regional Economic Strategy, the Framework of Regional Employment and Skills Action, and the North West Health Investment Plan. Together, they demonstrate the potential increase in the beneficial impact of the Health Service on society, and how a focus on prevention can be included in policy making and the allocation of resources. Additionally, the Health Service is a business with huge economic clout, and – until now – its role in urban and rural regeneration has been underestimated. One example of the benefits of ensuring that regional strategies and policies converge is the planning around the growth of the health care sector over the next five years. This makes the NHS one of the largest sustainable employers, creating a demand for more staff, which will make the regional health sector a key economic regenerator. This increased demand for staff must be included in our strategies on employment and skills development, if we want to increase the number of trained and qualified people in the region. And, in a virtuous circle, the health sector can help us to meet some of those targets, if we plan properly. Looking beyond the NHS, a healthy workforce helps to develop a competitive economy in the North West; but to create a healthy workforce, we need to improve the general health of the community, and develop and improve healthy workplaces. So in the Northwest Development Agency we are focusing more on the health agenda. We want to stimulate economic development in a way that has an added outcome of health improvement – for example, by looking at how economic development can be achieved in areas of poor health, because we know that employment is a major determinant of a community’s health status.

The health sector as a procurer of goods and services When we start to look at the health sector as a business, and a procurer of goods and services, many opportunities become apparent. We can develop supply chains in support of regional and local economies – for instance, the NHS and the education sector will soon be providing a piece of fruit each day to all 4-6-yearolds in school. In the North West alone this programme will have a value of millions – so this health promotion initiative is adding greatly to economic development by providing the demand side of a new market. Perhaps a consortium of regional fruit producers could organise themselves to provide the contract to supply this market – otherwise the fruit may be purchased from suppliers outside the region.

A North West health sector cluster We want to encourage the creation of potential virtuous circles like that. One way of ensuring this is to develop a health sector ‘cluster’, on the model of the Cheshire chemicals sector cluster for example, where we are supporting the development of new businesses to build on current strengths. Clusters encourage an integrated approach through efficient procurement and effective recruitment training and Higher Education links, including research. It works for aerospace, chemicals, biotechnology, environmental technologies and so on – so why not for health? The NHS is currently investing £300 million in a Private Finance Initiative for new-build health care facilities in Merseyside; these facilities will generate micro-businesses such as florists, newsagents and other enterprises serving the staff and users of the facilities. So when economic development and health planners get together, one of the topics they should discuss is how to support sustainable micro-businesses around such a big health cluster, to create added value. But this does require a ‘buy-in’ from the health sector – the NHS needs to identify what added value it can give to economic development in this region.

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Health and regeneration Let us now look at the complex issue of regeneration. One aspect is the design and quality of health facilities, which in the past have been very utilitarian. Part of regenerating local communities is improving the visual environment, and that includes improving the quality of primary health care premises. Another aspect is people, and their capacity to contribute to social and economic development. Here is another virtuous circle – a healthy economy gives people choice, and also allows us to apply the nation’s wealth to tackle the causes of deprivation. Again we see how the health and regeneration agendas overlap. North West England has more than its share of problems: 35% of wards are in the UK’s worst 20%, and we have 49 of the country’s worst 100 wards. Almost three million people are directly affected. We need to implement an integrated and comprehensive approach to community-based regeneration, and tackle economic exclusion as part of an integrated programme of action. Our aim is to develop sustainable communities through a balanced programme of action, including economic underpinning, educational attainment, improvement of housing and public services, tackling crime and improving health. To achieve this, the health sector must become an active and influential partner in community-based regeneration programmes. The health sector can also contribute to regeneration at other levels. Capital building programmes by Primary Care Trusts and acute Trusts can have a massive impact on local communities – for example, NHS investment in a new primary care centre in Cumbria will probably be one of the biggest regeneration projects in that community; such initiatives are especially noticeable in rural areas, and they provide an opportunity to lever in other resources on the back of NHS investment. The Human Resources (HR) policies of the health sector are another opportunity. In the North West 320,000 people are employed in the sector; it has a high turnover (20% plus), and its services are expanding. If we forecast only a 15% turnover, that means 50,000 vacancies a year. We know that there are 118,400 people unemployed in the North West. They are concentrated in the worst 20% wards, where we can find around 100,000 unemployed people. The potential for impact is obvious. If we add to that the 288,000 people employed by local government in the region, we can see how the health and local government sectors could have a dramatic impact on employment in disadvantaged communities. But we need a single-minded focus, to create a win-win situation. The health sector, the Northwest Development Agency, Government Office North West, the Regional Assembly and local authorities must all act together to make sure it happens.

Areas for discussion I will end by suggesting five fruitful areas for discussion between the economic development sector and the health sector. First, loss of working days due to ill health; second, cluster development as a way to maximise the impact of health sector business on the regional economy; third, how the health sector can fulfil its role as a major partner in regeneration; fourth, the potential positive impact of capital programmes on community regeneration, and lastly, the impact of Human Resources policies on economic exclusion.

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Joining forces to invest in health Steve Machin Chief Executive, North West Regional Assembly The North West Regional Assembly has two particular areas of responsibility: the framework for regional planning through the Regional Planning Group, and the framework for sustainability through the Action for Sustainability programme. But there are also other overarching issues, equally pertinent to all regional bodies: the role of the public sector in the regional economy; health and social care; economic development and employment. The health and social care sector contributes 6.7% GDP to the North West economy. It has an economic and employment role, extending beyond providing services, meeting health needs and reducing inequalities. The sector spends over £6 billion per annum, 60% of this on staff with £2 billion on goods and services. Some of this is spent in the North West but there is considerable leakage. Reducing this leakage is vitally important for the regional economy and for increasing the effectiveness of health and social care policies. It is also important for maximising the benefits of increased expenditure and investment, and for the sector to train and retain staff to provide new and expanded services.

Major employer The sector employs nearly 190,000 staff (6.7% of employment in the region). When indirect and induced employment is taken into account, the health and social care economy supports 413,000 or 14.6% of jobs in the region. It is therefore a significant employer and influences jobs in other sectors. The sector has strong links with manufacturing industry in the region, particularly the manufacture of medical and surgical equipment and pharmaceuticals. It also has a key role in medical research and training.

Impact on the regional economy Health and social organisations spend about £2bn per annum on goods and services – the extent to which this is spent in the North West has a significant economic effect on jobs and the regional economy. The contribution of the health and social care economy has been understated and hence the Regional Economic Strategy has failed to fully recognise the economic and employment importance of this sector (this has been addressed through the Regional Economic Strategy review process). This is applicable to other public services such as education and housing and regeneration. This briefing paper develops a model by which health and social care and other key public sectors can be analysed and policies developed to enhance their economic contribution to the region.

Planned growth Health and social care expenditure and investment is planned to increase by about 37% in real terms between 2002/03 and 2007/08, creating about 12,000 new health care jobs in the North West, plus additional jobs in the social care sector.

Direct impact in reducing health and social inequalities The economic and employment role of the health and social care economy can make a significant contribution to reducing health and social inequalities through targeting of employment and by increasing the regional share of expenditure on goods and services. The health and social care sector employs a large percentage of women and black and ethnic minority staff, it has a wide-ranging skills and earnings profile with significant career opportunities, and is highly committed to training.

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Benefits could be undermined However, the regional benefits could be undermined by further privatisation in the health and social care sector, the continued use of the Private Finance Initiative and the transfer of services and assets from the public to the private and voluntary sectors. Two-tier workforces, reduced terms and conditions for transferred and/or new staff and inferior pension schemes ultimately reduce earnings and spending in the regional economy. I would like to set out a manifesto for change, which can help us all achieve our objectives, of greater prosperity, and better health and quality of life for all in the North West. First, we need to align the Regional Economic Strategy, regional planning guidance, Action for Sustainability and the health improvement programme at all stages of projects and policy development, to ensure they are consistent and adding value to each other; this means that all sectors need to have conversations with each other. Second, we need to join up working between the Department of Health, the Northwest Development Agency, Government Office North West and the North West Regional Assembly, and ensure complementary performance measures and targets. Third, we need to translate theory into practice and set up pilot projects to demonstrate that joined up working through the Regional Investment for Health strategy works. And fourth, we must ensure joint communication and consultation, to see that all this happens. There are some new opportunities to integrate health into regional policy. From January 1, the Regional Assembly and local authorities have the power to set up health scrutiny committees. They have the right to ask questions about the integration of health into local and regional strategies â&#x20AC;&#x201C; for example, if the NHS is investing ÂŁ3bn in a new hospital, scrutiny committees can ask how the NHS will make sure that jobs go to local people. Another opportunity lies in the new roles and functions of regional assemblies as specified in the 2002 Regional Government White Paper (Your Region, Your Choice). These include a public health function, involving health and regeneration, for the Regional Director of Public Health. We can also ensure the integration of health into wider sustainable development agendas, for example through NHS trusts developing plans for sustainability, meeting environmental quality standards and addressing regional targets on pollution and energy use.

Policies needed to maximise the regional benefits of a growing health and social care economy Finally, the regional partners need to examine and develop policy responses to a number of key issues. These range from focusing on regional and local procurement to countering the increasing centralisation of procurement; harnessing spin-offs within the region; integrating the expansion of health expenditure and investment with regeneration, urban and rural renaissance schemes; ensuring the modernisation agenda does not accelerate privatisation, and examining the implications of existing health care employment, demographic change and the location of health care investment for spatial development under the Regional Planning Guidance. In January 2003 the NWRA will publish An Economic Analysis of Health and Social Care Expenditure and Investment as a contribution to the draft North West Health Investment Plan. This will be our contribution to continuing the debate which is vital both for our public services and for our regionâ&#x20AC;&#x2122;s economy.

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Claiming the health dividend – the evidence and the national picture Jeff French Executive Director, Health Development Agency This presentation examines the link between regeneration and health development, the evidence for the impact of regeneration on health and the contribution of the health sector to regeneration, building on the King’s Fund report Claiming the Health Dividend. It ends with an overview of the Health Development Agency’s work in this field.

What is health development? The World Health Organisation Health Promotion Glossary defines health development as ‘the process of continuous, progressive improvement of the health status of individuals and groups in a population.’ Below is a model of the main influences on health development, both individual and social.

Genetic

Somatic

Psychological

Health development = Well-being

Social Development

Civic Development

Economic Development

Physical Development

Ecological Development

The impact of regeneration on health: The evidence Before we look at the evidence for links between regeneration and health, we need to acknowledge the difficulties in gathering and interpreting such evidence. Regeneration is complex – do we evaluate components or whole initiatives? And we have a wide choice of evaluation frameworks, from health impact assessment through participatory research to theories of change. There are also a variety of study designs, including randomised controlled trials, before-and-after studies, retrospective surveys, participatory action research and so on. Even when we have chosen our theoretical framework and methods, we find that many regeneration programmes have poorly specified health objectives and outcomes. Finally, the more comprehensive the evaluation, the longer it takes to complete, and the more out-of-date it is when completed. With those caveats, we find that the evidence shows improvements in self-reported health, improvements in health behaviours, higher rates of community participation and social interaction, changes in prescription rates for asthma drugs and medication for depression, improvement in reported episodes of ill health and a reduction in poverty and debt associated with dampness and energy inefficiency. But we also find some harmful consequences of regeneration, including stress resulting from the upheaval of re-housing and relocation, increased rents (so less money for other necessities), lack of control for residents involved in regeneration and a reduced sense of belonging.5

5 Popay, J (ed) (2001), Regeneration and Health: A Preliminary Review of the Literature. Kings Fund.

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The evidence also shows that certain key processes are more likely to increase the positive outcomes and reduce the negative ones. The advice from best practice is, Be strategic and holistic, target resources and avoid dilution, relate planning and delivery to needs, emphasise results and learn from what works, mainstream rather than add on, break down boundaries, find new forms of partnership and build community capacity.

The NHS and health development To return to health development, there are four potential contributions that the NHS can make to public health development. First, through its direct care, cure and prevention services; second, through organisational and community capacity building; third, through the impact of its organisational ‘footprint’, and fourth, via its specialist and generalist public health services. This conference is focusing on the third contribution, the potential impact of the NHS’s organisational footprint. This includes employment, purchasing policy, buying childcare, buying food, waste, travel, energy and building. This is a huge opportunity to realise the NHS’s potential and to provide a model for the rest of the public sector; this can be done by building on support, provoking debate, making the connections and creating incentives.

The role of the Health Development Agency The Health Development Agency is keen to be part of this approach, in a number of ways. We are following up the Claiming the Health Dividend report through work with the King’s Fund to build up a searchable database of best practice on issues identified in the report such as local procurement and childcare. We are also building regional health and regeneration links, for example by providing an evidence base for action across health and regeneration sectors. Currently we are assembling the evidence base on housing and health, transport and health, community safety and health and employment and health. Finally we are promoting health impact assessment and integrated impact assessment, for instance by facilitating the development and piloting of a North West regional integrated impact assessment tool.

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Tackling health inequalities through anti-poverty strategies and the role of the health services – recent experience from Ireland and Europe Sara Burke Institute of Public Health in Ireland

The Institute of Public Health in Ireland The Institute is a very new, young, small organisation, working on an all-island basis, with offices in Dublin and Belfast. The organisation has a remit to promote co-operation, North and South, on public health issues, with a particular focus on reducing health inequalities and influencing public policies in favour of health.

Work on health inequalities and poverty in Ireland In 1997 the Republic of Ireland was the first country in Europe to adopt a National Anti-Poverty Strategy (NAPS). Institutional mechanisms are in place which oversee the implementation of NAPS and ‘poverty-proofing’ has been introduced across all government departments to ensure that policies do not lead to an increase in poverty, and ideally reduce it. NAPS places emphasis on inter- and multi-sectoral working. In Northern Ireland there is a Programme for Government which makes clear commitments to tackling inequalities; there are also equality measures, and a recently published public health strategy, Investing for Health, which lays down a very exciting blueprint for tackling health inequalities, based on the determinants of health. It is the result of a very extensive consultation process and is very cross-cutting in nature, driven by a Ministerial Committee on Public Health with ministerial representation from all relevant departments. The principles and values are very inclusive and rights-based and there is a very strong emphasis on partnerships and local community engagement for successful implementation.

The international context Internationally, there is a very supportive context. The 2000 World Health Organisation (WHO) Report on Macroeconomics and Health outlines why good health is critical to a nation’s prosperity. (Unfortunately, it has taken the AIDS crisis in sub-Saharan Africa to highlight this, with some countries’ chance of economic stability being eliminated for the foreseeable future as so many people of working age are unable to work due to HIV/AIDS and early death.) The UN Millennium Development goals are relevant and the recent World Summit on sustainable development is also a useful backdrop. In Europe, the European Union is increasingly setting the European agenda on social issues, influencing and supporting national government initiatives to address linked poverty and health issues.

Combining policies and interventions There is a growing consensus internationally on the types of action that are necessary to reduce poverty and health inequalities. A recent book on the subject edited by Mackenbach and Bakker emphasises the need for a combination of policies and interventions to reduce health inequalities.6 It is not an ‘either or’ between redistributing income (‘upstream’ approaches) and more effective health service provision for the poor (‘downstream’ approaches). For example, long-term/upstream approaches could be socio-economic distributions, the mid-term/midstream approach could be reducing exposure to unfavourable conditions, i.e. improving the environment in a particular estate or community through safe play areas, street lights, footpaths and better heating in houses. And more short-term or downstream approaches could include health care interventions that prevent poorer health such as better access to primary care in deprived neighbourhoods or improving the health of those living in poverty by working with other sectors to develop and implement the midand upstream approaches.

6 Mackenback J, Bakker M. Reducing inequalities in health: a European perspective. London: Routledge, 2002

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Four kinds of initiative on poverty and health Here it is useful to draw on the work of the World Health Organisation’s European Office. The WHO Europe Poverty and Health Programme has been gathering case studies on how health systems in Europe are positively affecting linked poverty and health issues.7 It identifies four kinds of initiative that health services can take to tackle poverty and health. The first is affordability of services – not specifically applicable to England as you have a universally provided National Health Service. The second is cultural and geographical access to services, particularly relevant to marginalised groups such as people living in rural areas, homeless people or migrant communities, who may need outreach or services which embrace cultural specificity. An example is how the provision of language and cultural mediators increased child immunisation rates of newly arrived immigrants in Italy. The third kind of intervention addresses poverty and the wider determinants of health directly. In St Petersburg an Urban Gardening Club works to increase the local production of vegetables, which are too expensive for many people to buy in the shops. Using new farming methods and selected varieties of vegetables that can grow on rooftops and other confined urban spaces such as schools, hospitals and prisons, they have started and sustained an increasing number of rooftop vegetable gardens. The fourth kind of initiative is the provision of more effective and accessible services for ‘diseases of poverty’ such as TB. This is about bringing the services to people who need it and often linking them in to services which can address the causes of their poverty, such as addiction or employment services. In Blackpool a GP surgery works with the Citizens Advice Bureau to help clients resolve financial issues which had led to high levels of stress and depression. In Newham, a ‘Fit for Life’ programme provides training for local unemployed people to fill positions in the health service and other businesses for which employers had struggled to recruit. There are also a plethora of examples in the Claiming the Health Dividend report on how the health services – through employment and procurement policies, through childcare, food, building, travel, waste and energy strategies – can claim the health dividend.

Opportunities in the North West Looking at the North West, there are a number of opportunities and proven methods to claim the health dividend. There is currently a positive policy and political environment to be exploited; in this time of change, there are opportunities to shift the paradigm from acute health service provision to public health and seamless effective health service provision. Have patience and vision – impacting on health inequalities takes time and leadership. Think in terms of packages of policies/ interventions which combine upstream, mid-stream and downstream approaches; monitor and review progress; build on knowledge, expertise and evidence; nurture and sustain partnerships, and develop local solutions to local issues. Involve people – communities and front-line workers – in decision-making; ensure work is based on inclusiveness and rights; share experiences within and between regions, and seize the opportunity to develop a ‘joined up’ agenda on health.

7 www.euro.who.int/document/RC52/ebd1.pdf

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Where does ‘health’ come from? Changing the views of the workforce Sue Antrobus Director, Royal College of Nursing Political Leadership Programme The Political Leadership Programme builds the strategic, political and advocacy capacity of senior nurse managers in Primary Care Trusts to enable them to play a full role in developments such as health and regeneration. Nurses are 70% of the NHS workforce, so any agenda which involves new ways of working has to engage the members of the largest occupational group. One of the contributions the RCN has made to this movement has been to consider how nurses can use their professional leverage to address issues of wider health, beyond the health care services.

The changing understanding of the NHS role in health There has been an evolutionary process of the NHS understanding its own role in health. At first the NHS focused upon treating illness and delivering health care; it then began to participate in health promoting activities, later working in partnership with other agencies to promote health. Now, if the NHS adopts the agenda of Claiming the Health Dividend, it will take the lead in acting as a strategic lever for health improvement and sustainable development. But how can the NHS make such a big change? First, it must invest in frontline staff at all levels, with training and development around wider policy issues. Second, it should develop the NHS and the people working in it as a central force in driving health and regeneration. And third, we must learn from innovations, and change the way in which strategy and policy are made. The NHS is good at allowing innovation in small one-off projects. The challenge now is to improve our ability to learn from pilot projects and to ‘scale up’ these successes. For further information please contact Sue Antrobus, tel: 01204 552440.

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Rural health and regeneration Tony Potter Executive Director, North Cumbria Health Action Zone

Recognising the urban in the rural What is rurality? The notion of a rural community in contrast to an urban one may be deceptive, if we accept the fact that at any one time the rural environment will be populated mainly by people from the urban environment, who are visiting, for varying lengths of time. The distinction between urban and rural then begins to fray at the edges. This helps in understanding how the factors which cause rural deprivation are often the same as, or related to, those which cause urban deprivation. For instance, in Cumbria the part-time occupation of rural communities by people from urban areas creates housing problems for those who live there full-time. Another example is the way in which tourism – the largest employer in rural areas of Cumbria – mainly provides low-paid, seasonal work which brings its own problems, many of which are more often associated with urban areas. Although ostensibly wealthy, areas like North Cumbria have pockets of urban-style deprivation which are too geographically small to attract the regeneration resources and area-based initiatives found in larger urban centres. Rural community life in these areas will only be sustained if economic development and health development resources are spread fairly across urban and rural areas.

Partnership Finally, some thoughts about partnership, which is more than just attending partnership meetings or working together. It is more than each agency keeping their own turf – their own resources and staff – while doing a joint project. The most fruitful partnerships are about sharing resources, staff and – ultimately – values.

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Opportunities for change

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The NHS and food Angela Towers Development officer, North West Food & Health Task Force

The NHS is the largest single purchaser of food in the country – how can it use its spending power to create jobs in areas of need? The North West Food & Health Task Force was commissioned by the Sustainable Development Commission to look into sustainable local purchasing of goods and services by public sector agencies, as a contribution to sustainable economic development. If we focus on the NHS, we find an annual spend of £500 million, including more than £300 million on meals for patients, staff and visitors, in 1200 hospitals. A typical national shopping list includes 250,000 litres of orange juice, 12.3 million loaves of bread, 61 million litres of milk, 1.1 million kg of butter, 1.3 million chicken legs and 13.5 million kg of potatoes.

The spending power of the NHS Three new food initiatives show the potential of the NHS’s spending power. The National School Fruit Scheme will ensure that all 4-6 year olds in schools will receive a free piece of fruit each school day; by 2004 the scheme will reach 2.5 million children in 16,000 primary schools, requiring 500 million pieces of fruit per year. The North West is receiving £2.5 million for ‘Five A Day’ community initiatives to promote fruit and vegetable consumption; the average consumption is three pieces per day, and the target is five per day – that is an increase of 3 million tonnes per year. And the programme for better hospital food, costing £40 million over four years, aims to improve the quality of the food service offered to patients and reduce food waste.

Hidden costs of central procurement Currently the food in all of these initiatives is sourced through the NHS Purchasing & Supplies Agency, which oversees the purchasing of all goods and services within health care system. The rationale is that national contracting allows for economies of scale and lower prices. But it is now becoming apparent that there are hidden costs, such as the generation of many extra journeys and restrictions on buying from local providers, which go against local economic development and the promotion of health and sustainability.

Benefits of sourcing locally Local sourcing of food has many benefits: the impact on the environment is reduced (the calculation of ‘food miles’ – the distance that food must travel – brings this out powerfully); local economies are strengthened, local jobs are created and protected, community ties are strengthened, the produce can be fresher and therefore healthier, and local culture and heritage can be protected.

Barriers But there are barriers to local sourcing, including European Union procurement legislation which requires that contracts above a certain value must go out to tender; the NHS currently has a national menu, and a lot of fresh food is seasonal. Within the NHS, local Trusts often do not have the capacity to source goods and services locally – this would require staff to identify all current contracts and then look for cheaper local providers of the same quality (of course a local supplier is not always available – which then highlights an economic development opportunity). Another barrier is the capacity of local growers and producers, both to provide the required goods and services, and to deal with the NHS’s contracting procedures.

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Practical steps to purchasing health and economic development The NHS at regional level is currently working with the Northwest Development Agency to tackle some of these barriers, with input from the Sustainable Development Commission. I will close by suggesting some steps that can be taken to increase local purchasing, and thereby boost the local economy and promote health at the same time. Trusts should consider the impact of their procurement practices, including ‘whole life’ costs when judging the price of ‘cheap’ food; environmental criteria should be included in tenders, and there should be greater communication between Trusts and their suppliers. Suppliers should be encouraged to consider cooperative working, in situations where no single local contractor is able to provide the product or service; there is a role for the Northwest Development Agency here in supporting small and medium-size suppliers to group together and bid for larger contracts. Within the NHS, staff skills need to be developed so that Trusts can achieve efficient, sustainable procurement.

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The NHS and training, education and employment Nigel Burke Director of Education and Social Inclusion, Government Office North West The NHS is the largest employer in the country – but in some areas it has difficulty in getting the staff it needs. How can the NHS realise its full potential as an employer and contribute to economic regeneration in areas of deprivation?

Role of Government Office North West The role of Government Office North West is to ensure effective delivery of Government policies and programmes, to help improve the region’s economic performance, ensure sustainable development, develop the region’s workforce and build sound communities. If we focus on education and training, the national priorities of the Department for Education and Skills (DfES) are to transform secondary education, develop a flexible 14-19 phase of education and training, to strengthen and support excellence in higher education, and improve access and participation, and to develop the skills of the workforce, particularly basic skills. In the North West, the key issues are the significant number of schools facing challenging circumstances, improving the skills of the workforce, raising participation in higher education and adult basic skills.

Meeting the challenge of NHS expansion Against that background, there will soon be thousands of new vacancies in the NHS. The NHS Plan set targets for short term increases in key staff groups, so that by 2004 (2005 for medical school places) there will be 7,000 more consultants and 2,000 more GPs, 20,000 extra nurses and over 6,500 extra therapists, 5,500 more nurses and midwives trained each year, 4,450 more therapists and other key professional staff trained, 1,000 more medical school places on top of the 1,100 already announced and 450 more GP registrars and 1,000 more specialist registrars. This is good news, except that the number of people currently in suitable training for these jobs is below what will be required. That is our challenge. The simple answer is to work better and work smarter, in our training and recruitment. By ‘work better’ I mean more collaboration, and by ‘work smarter’ I mean more linking of objectives across different sectors so that we can achieve more outcomes for the same amount of effort. To do that, we need to develop projects which show how we can realise the benefits of the growth in NHS spending on staff, while increasing the regional pool of trained, skilled and qualified people.

A regional pilot project One such initiative is the Workforce Development Project, which aims to provide a route into employment in the health care sector for people from deprived and minority communities. The project steering group consists of myself (Government Office Education and Social Inclusion Director), a representative for the three regional NHS Workforce Development Confederations (these hold budgets for all NHS training, professional education and professional development), a representative for Learning and Skills Councils in the three pilot areas, representatives from Jobcentre Plus and from the trades unions. In the first phase of the project we tried to identify the barriers which come between people who are socially excluded and job opportunities in healthcare. The second phase will try to overcome these barriers in three pilot areas, Blackpool, Halton and Oldham. The targets or intended outcomes are the development of basic skills, preemployment preparation, employment, evaluation and dissemination of good practice, and the trialling of aspects of the NHS University (NHSU), which is being established to give all staff an opportunity to to train and develop.

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Communities as a source of benefit rather than cost In conclusion, there are many opportunities to use the leverage of the NHS as the largest corporate purchaser of training and education in the region. However, we need to start seeing communities as a source of benefit rather than cost. The advent of the Workforce Development Confederations last April provides the North West with a valuable and dedicated resource to address the future development and recruitment needs of the health care sector. Another opportunity is the development of favourable policy, which allows the education sector and the health care sector to work together on this agenda. Some examples of favourable policies are the NHSU, developments in the 14-16 phase of education and indeed the 14-19 phase of education, reform of further education, widening participation in higher education and the drive for adult basic skills.

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Case studies: NHS capital projects Participants worked in small groups, assessing the potential health dividend in planned NHS capital projects around the North West, and discussing issues raised during the day. Participantsâ&#x20AC;&#x2122; detailed comments are included at the end of each case study where relevant, and more general comments relevant to all the case studies are included on Page 32-38.

Working with whole systems Why use the Whole Systems approach to tackle this agenda?

It brings together the major stakeholders to interact with each other around the health and regeneration agenda

Creates a new network of relationships across the region

Gives people the opportunity to hear first-hand different perspectives on the component parts of the topic

Has the capacity to facilitate reassessment of policy and planning

Creates broad ownership and commitment to the issue/agenda

Helps people appreciate the whole system and their part within it

Has the potential for aligning all the stakeholders around a change effort.

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Case study: Merseyside and Cheshire Health Authority area Future Healthcare Project, Liverpool Budget: £200 million approx The Future Healthcare Project was established to address the need for major investment in the Liverpool’s general hospitals – the Royal, Aintree and Broadgreen. The strategic aims of the Future Healthcare Project are to:

Address the changing healthcare needs of the public

Meet acceptable performance targets in all service delivery areas

Take into consideration National Service Framework (NSF) and other national good practice requirements

Embrace available emerging technology, e.g. telemedicine

Provide a service environment in which our hospitals of the future embrace the NHS Plan and deliver modernised hospital and community services fit for the 21st Century

Provide a first class teaching, research and service development.

The environment in which services will be provided, both in hospitals and the community, will be to the highest modern standards and services will be delivered in a patient focused and friendly manner. In addition the project will be working closely with the City Council to ensure that the scheme supports and is supported by regeneration activities and programmes. There has been significant analysis of future demand for health care to ensure as far as possible that capacity will meet the future needs of the catchment populations. There are currently no cost estimates available for this project, but a capital investment of less than £200 million is unlikely to meet the project aims. An outline business case for the scheme will be completed during 2003. If approved a start on the developments is envisaged for 2007.

Participants’ comments Strategic aims should be added, addressing:

health improvement of local people

engaging local communities

partnership

Sustainable building

A sustainable transport plan should include people travelling to the development for regional specialisms. Information technology (e.g. telemedicine) could assist this.

A composting business should be built into the design, and provided through an Intermediate Labour Market.

Training and skills development

The Liverpool Construction Initiative and Fusion 21 should be linked to this development.

Partnerships

Ensure that the partnership is inclusive, e.g. include New Deal for Communities, Merseytravel and Greater Merseyside Enterprise.

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What are the overlapping agendas?

Local training and jobs â&#x20AC;&#x201C; overlaps between Liverpool City Council construction initiative, Fusion 21 initiative and Customer Service project (Liverpool Business Centre).

Potential barriers: Sub-regionally:

Politics between Cheshire and Merseyside areas

Locally:

The different cultures of the main partners (the NHS and the city council).

Potential opportunities: Locally:

The development of local procurement policies across Merseyside

The use of information technology to develop care in other settings such as Primary Care, Healthy Living Centres, cyber centres in GP surgeries and community centres.

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Case study: Greater Manchester Health Authority area Salford Health Investment for Tomorrow initiative Budget: £175 million approx The Salford Health Investment for tomorrow (SHIFT) and Local Improvement Finance Trust (LIFT) are uniquely placed to contribute to the regeneration of the city. Salford Health Investment for Tomorrow (SHIFT) is a whole system service design and capital improvement initiative, with the improvements to Hope Hospital being procured through a Private Finance Initiative. A Strategic Outline Case, largely focussing on the replacement of substandard buildings on Hope Hospital site was approved in February 2001. Subsequently, a broad range of service redesign activity has taken place, aiming at re-engineering services to better meet the needs of service users, and designing modern facilities which are fit for purpose. The SHIFT initiative is supported by the Prince’s Foundation, with a view to ensuring excellent building design. The Outline Business Case received approval from Salford Primary Care Trust, as Lead Commissioner, in August 2002, with an overall value of £175 million. Through early discussion with the Prince’s Foundation, other partners and a community adviser, we have identified the potential for additional regeneration activity in the area surrounding the Hope Hospital site, which could bring benefits to the local community and maximise the sites as a community facility. As a partnership, we are keen to explore this further. A network of eight local centres for health and social care, starting with developments in the four town centres, followed by improved facilities in the outlying areas, are under development. A key feature of the centres will be the provision of a range of health and social services under one roof, in order to maximise uptake. The centres are also likely to contain commercial outlets and community facilities. Each of the four major centres will have a distinct focus, with a children’s centre in Pendleton, specialist rehabilitation in Walkden, minor surgery and diagnostic procedures in Swinton and an education facility in Eccles. The partnership is keen to identify future support in maximising the regeneration potential of the development.

Participants’ comment Who is responsible for pulling the partnership together? For example, East Manchester has attracted £80 million of regeneration money, New Deal etc, because it is someone’s job to pull it all together.

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Case study: Cumbria and Lancashire Health Authority area Developments in Burnley, Bacup and Stacksteads Budget: £3 million and £4 million approx

Burnley There is likely to be major capital investment within healthcare in Burnley within the next five years. Detailed discussions are taking place about a major Private Finance Initiative (PFI) to re-provide acute hospital care in new accommodation. A preferred bidder has been identified and the scale of the capital re-development is likely to be of the order of £3 million (?). A Local Improvement Finance Trust (LIFT) is also being developed to improve and re-configure primary care accommodation across the whole of East Lancashire. The aim of the projects will be to:

significantly improve the quality of accommodation in both primary and secondary care, ensuring it is fit for the 21st century

make Burnley a more attractive place for health professionals, particularly General Practitioners, to work in. There is a serious shortage of GPs in Burnley, Pendle and Rossendale.

One of the major challenges is to think through how the NHS can work with private sector partners to deliver the health dividend. This is potentially very significant capital investment in an area in desperate need of regeneration, but the NHS’s role in PFIs tends to be more hands-off. How do we make PFI a vehicle for regenerating the economy? How can we connect these two separate projects together to deliver a bigger health dividend? How do we connect other schemes in the East Lancashire area (e.g. housing) to put added value into the system?

Bacup and Stacksteads Bacup is a small town of about 15,000 people high up in the Pennines, with a very active, enthusiastic voluntary forum pushing ahead with an agenda for reform. One example of claiming the health dividend was the impact of £50,000 from the Primary Care Trust which enabled Bacup and Stacksteads SureStart to buy a disused swimming pool for conversion into offices and a day centre.The money ‘kick-started’ SureStart and brought in a further £750,000. In the coming year a derelict mill will be converted into a new health centre under the East Lancashire LIFT initiative, to replace the wholly inadequate current facility in this remote area. It will cost £35,000 to buy, £400,000 to demolish and £4 million to convert the building, but the impact on the regeneration of the town centre, on the prospects for health improvement for 15,000 people, and on the sense of well-being of the community could be immense. It is also hoped that the new facilities, and their knock-on effects, will attract and retain health professionals to this part of East Lancashire.

Participants’ comments

Current accommodation should be monitored using asset registers.

Local residents should have an influence on the way NHS resources are used. If they are not involved, there could be problems with opposition to the development (involving residents is challenging, especially ‘average’ residents without a specific interest).

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Comments relevant to all case studies What are the opportunities presented by these developments? New capital developments should be (flexibly) based on projections of demand for services, taking into account changing demography, and the role of the voluntary and informal care sectors. They should also be based on the needs and local expertise of residents (geographical communities) and communities of interest in the new facilities’ catchment area, with site maps showing how the facility fits into the wider community, as a matter of principle. Rigorous integrated appraisal should be done at an early stage, linked to local Community Plans, and results of other public consultations, e.g. by SureStart, should be consulted. The Local Strategic Partnership is the natural umbrella under which all of this should be done.

Employment

Employment of local people to build and staff new health facilities should be encouraged, e.g. through advertising locally, providing training and support to encourage applicants who have been long-term unemployed or who have mental health problems, and finding roles for retired people. This can be done through building links with local schools and colleges and initiatives such as Intermediate Labour Markets – all of which have short-term costs.

Sustainable procurement

The community should be involved at the preferred bidder phase, the selection phase or earlier, through the Local Strategic Partnership. Local firms should be enabled and encouraged to bid for construction and supplies contracts. Local people should be encouraged to provide new services which meet the project’s identified needs – this could lead to new ways of delivering services (diagnostic centres etc.). A sustainable procurement strategy is required, otherwise the cheapest option will be the only option, e.g. contractor specifications should include environmental policies.

Sustainable building

Use an environmental assessment and monitoring system such as BREAM; ensure waste disposal is clean and minimal, e.g. composting waste food for use in the grounds (landfill tax funding could support this). Where there is a choice, the location and orientation of the building should be influenced by sustainability factors, e.g. amount of south-facing roof space for solar panels, a location which will make travel as fast, easy and environmentally friendly as possible, ‘designing out crime’. Transport that is reliable, safe, sustainable and affordable should be on offer to staff and users, to reduce car use. The building should be attractively designed, accessible to disabled staff and users, well insulated to enable low energy consumption, containing no harmful substances, and capable of multi-use. Landscaping should be attractive and allow recreational use, e.g. allotments to grow food – European funding is available for environmental work. All such factors should be included in tendering criteria.

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Local labour

Tendering procedures should be simplified and reassessed to ensure that they encourage local employment and sustainability (this also applies to procurement). The advantages of local labour should be balanced with ensuring equal opportunities. ‘Ownership’ of the new facility will be stronger if local people are involved in building and staffing it. Support with job applications should be offered to local people, e.g. through housing associations.

Training and skills development, e.g. how can local communities be supported to access new job opportunities?

The NHS could collaborate with local partners in building the capacity of local people (European funding is available). Training and recruitment drives should be held near to the new facility, to demystify the NHS and show the range of opportunities, including non-health care jobs. Possible partners are schools, education authorities, the Learning & Skills Council, SureStart, Jobs, Education & Training (JET) centres or equivalent, JobCentre Plus and local colleges and universities. Training and skills development should focus on transferable skills (there are many examples of good practice), using NHS Workforce Development Confederation funding to train health and social care workers on a ‘skills escalator’ – this relies on middle managers using staff in new ways, and on the erosion of professional barriers, e.g. healthcare assistants doing tasks previously done by professionals. Such changes would affect future demand, e.g. less GPs may be needed if primary care workers are given additional support. This skills escalator policy should also apply to care workers in the private and voluntary sectors.

Partnerships

Possible partners include New Deal for Communities, local authoriites, Single Regeneration Budget (SRB) programmes, further and higher education institutions, Learning & Skills Councils, Primary Care Trusts, transport operators, chambers of commerce and enterprise agencies, NHS Direct and other providers and developers of telemedicine, Community Safety Partnerships, NHS Workforce Development Confederations and access groups.

What are the overlapping agendas? An example may be ICT Strategy (NWDA) and IT Development (NHS)

Development of basic skills – overlap between NWDA, education authorities, Education Action Zones, further education, Learning & Skills Councils and New Deal for Communities

Community involvement – overlap between Local Strategic Partnerships, PCTs, Health Action Zones, local authorities, the voluntary and community sectors

Inward investment – overlap between PCTs, NWDA, chambers of commerce, enterprise agencies, DTI (National Strategy for Social Enterprise) and local authorities

Sustainable transport – Local Transport Plans, public transport operators, PCTs, Strategic Health Authorities, campaign groups and local authorities

Local Agenda 21, locally and regionally overlaps with most of the above.

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What are the barriers/opportunities?

Region

Barriers

Opportunities

Bidding

Added

Policies

The

processes encourage competition, not collaboration which move the pressure from one area into another

Regional

reorganisation leads to confusion of responsibilities for users

value of integrating government programmes challenge of balancing regional strategy with locally determined strategy, e.g. Community Plans

Too

many separate funding streams and bids

Confusion

between health, and health &

social care Lack

of representation of local communities

Politics Negative

Subregion

stereotypes of localities

The

massive agenda for the NHS and partner agencies could squeeze out health and regeneration

Too

many separate developments and initiatives

Locality

Trying

to solve too many problems rather than focusing on single issues.

Reluctance

of employers to hire local people

Middle

managersâ&#x20AC;&#x2122; lack of vision and flexibility to make or allow changes, and to use new staff roles effectively

Failure

to engage frontline staff

Lack

of capacity in trusts to source local supplies

Procurement

rules

Difficulty

of creating wide-ranging project teams

Lack

of public health capacity at Strategic Health Authority and PCT levels

Funding

and performance indicators operate against good practice and innovation

Resistance

to change of GPs (operating as small businesses) and expectations of patients (e.g. suspicion of telemedicine)

Tendency

to deliver services with clinician in mind, not the users

Health and regeneration Report of a conference 34

The

NHS as a partner in Local Strategic Partnerships

Harnessing

the skills and experience of local communities, e.g. in deciding how money is spent (using a cost/benefit consultation approach)

Local

Strategic Partnerships are encouraging â&#x20AC;&#x2DC;hard to reachâ&#x20AC;&#x2122; communities to take up education and employment opportunities

New

money could bring people together

European

funding

Opportunity

to work with local people and develop capacity to consult and improve health

Technology

may make it easier to access information rather than seeing a health care worker

services provided on a social enterprise model, with local people sitting on the board

Linking

health investment plans to local outcomes

Locality

Barriers

Opportunities

Trusts

Human

Organisations’

NHS

focused on national rather than regional targets lack of understanding of time obligation involved in partnership and whole systems working

Use

Resources policies, e.g. childfriendly policies Local Improvement Finance Trusts

of jargon

Poor

communication, within and between agencies, at all levels

Cost,

disruption and personal stress of changes in working practices in health and social care, in public, private and voluntary sectors

Suspicion

from local communities, about telling the truth, inclusion, raising expectations, openness and transparency

Public

sector’s perception of local communities as representing only a set of needs, ignoring their assets

Lack

of community involvement and influence

Focus

on geographical communities at expense of communities of interest

Lack

of a function that pulls the health and regeneration strategy together

Disinvestment Lack

in existing resources

of revenue to deliver proposed services

Loss

of control if projects become ‘political footballs’ at Ministerial level

Political

problems of closing substandard institutions

Disparity

between regional boundaries and health boundaries

Lack

of accountability in organisations outside the NHS to take part

Delays

through slippage, disorganisation, lack of project management skills, lack of contractors

Failure

to do Health Impact Assessments

Access

to technology could be limited to IT literate

Health and regeneration Report of a conference 35

Do you have access to the information/data needed to tackle this agenda? We lack information on:

the objectives of other players

the health of populations

local health plans

demographic and socioeconomic data

baseline lifestyle and morbidity data from GP records

If not, do you know where/how to get it?

Health Development Agency (practical examples of what works best)

2001 census, small areas statistics 2002-3

North West Public Health Observatory

Medical Information Systems, the Regional Intelligence Unit, local authorities, acute trusts

Public user surveys.

We need integrated information so we can agree on joint priorities, which will lead to integrated action. Further development of electronic patient records will help. Much of the information is available, but buried in a huge amount of other information. We also need to consult in a broad way, not just ‘Do you want x?’

Would it be helpful to have this event as a ‘standing conference’ for the next three years to monitor progress on this agenda? Yes – an annual event could encourage the sharing of experience, development of networks established at this conference, development of the agenda, and a focus on examples of good practice (and bad practice!). The event could be brought to local communities, to encourage involvement, and there should be a better balance between frontline staff and policy/strategy staff. The event should be linked to the Regional Assembly. Delegates should be provided with usable information from such conferences, and challenges should be set, to encourage progress (but how comfortable would organisations feel about a commitment to a conference accompanied by challenging targets?).

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Do you have any other suggestions for maintaining commitment and driving this agenda forward? Delegates should be encouraged to cascade information from this event.

Regionally

Establish a regional steering group; clarify accountability, commissioning role etc. Ensure that future strategic sites are identified across partnerships â&#x20AC;&#x201C; this could be a major role for Strategic Health Authorities who hold the budgets. Regional targets should be extended to sub-regional level, by the allocation of outcomes and indicators to organisations.

Sub-regionally

We need to enable non-NHS people to â&#x20AC;&#x2DC;bendâ&#x20AC;&#x2122; their work to meet health targets.

Locally

We need a process to enable us to deliver the regeneration agenda as an integral part of other NHS targets. We should encourage acute trusts and other statutory agencies to look at Human Resources and procurement policies. Within Trusts, we need shared responsibility and win-win management; targets should be agreed for programmes, and money should be made available against local targets (quality bond). Targets have to be mandatory, not optional, across agencies which deliver to the same agendas (health, education etc). Include health and regeneration in the targets of public sector chief executives. Use Local Strategic Partnerships to engage those not directly involved in the health field, and to ensure representation of local communities and business in taking the agenda forward.

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Key messages from round table discussion groups ‘Round table’ groups wrote key messages to be displayed during the plenary session:

Hospitals and trusts need to fully understand what the health of community really means; health is much wider than the biomedical model.

Management capacity and capability needs to be developed.

How do we develop the capacity to manage change in the short term?

How do we make this activity a ‘must do’, with targets and performance indicators? Any inspection and performance monitoring should encourage and value imaginative innovation.

Build these perspectives into commissioning and contracting.

A more explicit relationship is needed between local, sub-regional and regional levels, and we need to involve to a greater degree local communities and partnerships in the development of projects.

We need more examples of win-win good practice, including more explicit examples of working together between levels (regional, sub-regional and local).

Continuing support and facilitation of this agenda/process is needed to enable partners to develop their role, otherwise they will just go back to ‘the day job’.

How to get community representation for regional strategy development?

How to make regional strategy development meaningful for communities?

We need a clearer regional vision across sectors.

The Integrated Impact Assessment tool is welcomed.

We need to develop education linkages (for all) and supply skills to develop health staff.

Partnership is not about superficial action and teams, it is about complementary action when apart.

Primary Care Trusts have to engage in Local Strategic Partnerships.

We need to tell the good news about successful examples – communication and PR is key.

Information technology can support these developments if access is made easy.

There is general interest in reviewing the progress of this agenda in the future – would an annual Claiming The Health Dividend event be useful to maintain momentum? Other ways of building on today include work shadowing and learning sets.

Everyone should cascade this information within their organisation and partnerships. A report should be produced and circulated.

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Comments on Regional Economic Strategy Participants were invited to comment on the draft Regional Economic Strategy:

Where do local people and their views and aspirations feed into this strategy? Should health inequalities be with another lead agency? Investment for Health is looking at how health can come out of the priorities of other agencies.

The embracing of public services and health is welcomed

How can NHS organisations think more widely?

Economic development is not an end but a means

Well-being and quality of life are missing

Sustainable development should be explicit

Health should be identified as a cluster.

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Investing in health John Ashton Regional Director of Public Health

The Regional Health Investment Plan The Regional Health Investment Plan is a strategic document focusing on regional level ‘value added’ activities. The purpose of the plan is to establish investment for health as a shared vision between agencies, and a basis for developing the health dimension of all policies; to clarify the roles and responsibilities of regional agencies; to identify jointly agreed priorities, and to establish an action plan. It is not a plan for the NHS, but for all sectors in the region; the NHS is just the lead body. The plan looks at the wider determinants of health, and therefore focuses on issues well beyond the delivery of health care.

Health improvement across all sectors The Investment for Health framework is designed to identify and implement the health improvement dimension of all policies, and to develop and apply health and integrated impact assessment. This will be done by focusing on health, prevention and inequalities; by aligning strategies, targeting investment and working towards short, medium and longer term objectives. Its aims are to tackle the wider determinants of health, to maximise the NHS’s contribution to wider regeneration and sustainability objectives, to mainstream the issue of inequalities within the NHS, and to strengthen primary care.

Tackling health inequalities The regional plan supports Tackling Health Inequalities, the Cross Cutting Spending Review from the Treasury, which is a national plan to reduce health inequalities. Its themes are breaking the cycle of health inequalities, tackling the major killers, improving access to public services, strengthening disadvantaged communities and reaching vulnerable groups. The priority areas for delivery in this national plan are, first, tackling the wider determinants of health, with regional and local priorities for specific areas, Local Strategic Partnerships, Neighbourhood Renewal Strategies, the mainstreaming of lessons from Health Action Zones, and a focus on vulnerable groups, children and young people, single parent families etc. The second priority area is the subject of this conference, the NHS contribution to wider sustainability and regeneration objectives, in employment, training and recruitment; purchasing and procurement; infrastructure and information technology, and environmental policies. Third is the mainstreaming of inequalities within the NHS to tackle access, quality, and outcome service delivery issues, and to focus on prevention; and finally, the strengthening of primary care services, particularly the workforce and facilities in disadvantaged and under-served areas.

Making it happen These national priorities for reducing the gap in health status between groups and areas will be delivered and co-ordinated by a cross-departmental group, who will define targets, set short- and medium-term milestones, and encourage a mix of national ‘must do’ and locally determined outcomes for NHS and local authority Public Service Agreements. The national plan will be integrated with the North West Health Investment Plan, to ensure regional value added activities, priorities, and a framework for local delivery. There will be performance assessment and management systems, local delivery programmes and the strengthening of local capacity.

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Action at all levels The plan will be delivered at regional, sub-regional (e.g. through Strategic Health Authorities) and local levels (e.g. through Local Strategic Partnerships), so everyone has a role to play. The regional and sub-regional functions will be to align and co-ordinate governmental policies and programmes including area based initiatives, to influence regional strategies including those on the regional economy, sustainability and planning, to co-ordinate performance review and development support across agencies, and to communicate health policies, identifying and disseminating good practice in policy-making, programmes, and projects. Regional and sub-regional bodies will also be responsible for integrating information and intelligence for policy development implementation and review (including evidence based standards for practice) and building organisational capacity at the regional and local levels.

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Update The Northwest Development Agency is keen to build on the momentum created at last September’s conference, and has pursued a number of initiatives to claim the health dividend. In 2003 the NWDA will commission a research project to identify the size and scope of the ‘economic footprint’ of the health and social care sector in the North West. This will identify the support needed to develop a health and social care cluster. The research project is being developed by a multi-agency steering group, including representatives of local, sub-regional and regional organisations. Comments from conference delegates on the Regional Economic Strategy review document were all fed into the review process and are reflected in the revised document due for publication in March 2003. Comments from the conference have also been fed into the development of the Regional Health Investment Plan, due for publication in March 2003. An NWDA Health and Regeneration website is being developed, to share information and to keep partner organisations up to date with health and regeneration activities. In December 2002 the chair of the London Development Agency and the NWDA’s head of health policy met Public Health Minister Hazel Blears, to establish more formal working relationships between all regional development agencies and the Department of Health, and to gain a commitment to work with partners on developing the ‘Claiming the Health Dividend’ agenda in the regions. Finally, the NWDA are funding the Shaping the Future project (Workforce Development to deliver Integrated Health and Social Care). The steering group for this project includes Workforce Development Confederations, Primary Care Trusts and Social Services departments from across the North West.

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Conference delegates Jayne Ashley Dr Frank Atherton Mark Atherton John Barber Geoff Barnes Trish Bartlett David Booth Dr Sally Bradley Laurie Brewis Colette Bridgman Jackie Burns David Cain Justine Cawley Maggie Chadwick Paul Chase Mary Choiseul Mrs Sheelagh Connolly Peter Counsell Margaret Cross Dr Alison Crutchley Mr Chris Dabbs Ged Devereaux Stuart Donaldson Mark Dooris Dr Calbert H Douglas Mrs Mary Douglas Lisa Driscoll Dr Dympna Edwards Nidi Etim Peter Flynn Helen Fothergill Peter Fox Brenda Fullard John Garrett Martin Gibbs Liz Gill Una Gordon Maurice Gubbins Dr Alan Hallsworth FRGS Dominic Harrison Peter Hart Kerry Hemsworth Peter Hewitt Sheila Hill Eric Hodgson Ian Homard Dr Ann Hoskins Karen Howell Jan Hutchinson Richard Johnson Vicky Johnson

North West Regional Assembly Kendal Northwest Development Agency Lancashire Rural Stress Network Wirral Primary Care Trust Salford City Council West Chester Regeneration Board Salford Primary Care Trust Carlisle City Council Dept of Dental Public Health, Ashton-Under-Lyne Cheadle Hulme Trafford NHS Trust North East London Workforce Development Confederation Cumbria and Lancashire Health Authority Northwest Development Agency South Lakeland Local Health Group Cheshire Social Services Yorkshire & the Humber Regional Directorate of Public Health Government Office North West Lancaster University Salford Community Health Council Manchester City Council Government Office North West North West Healthy Setting Development Unit, University of Central Lancashire University of Salford Salford Royal Hospital NHS Trust Halton Borough Council North Liverpool Primary Care Trust Northwest Development Agency Director of Health and Social Care-North (Public Health) Lancaster Local Health Group Environment Agency NHS North West Regional Office Liverpool & Sefton LIFT Department of Health Government Office North West Liverpool & Sefton Public Health Partnership Northwest Development Agency Manchester Metropolitan University Health Development Agency North West North West Regional Assembly Cumbria and Lancashire Workforce Development Confederation Social Services North West New Heart for Heywood New Deal for Communities Partnership 5 Boroughs Partnership NHS Trust Northwest Development Agency Cumbria and Lancashire Health Authority Regional Prison Health Taskforce â&#x20AC;&#x201C; North West Bolton Primary Care Trust Patient Safety & Involvement Walking The Way to Health Initiative

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Fiona Johnstone Mrs Gwyn Jones Ken Keith Simon Kenton Jayne Kerwin Dave Kidd Pernille Kousgaard Dr Alyson Learmonth Jean Llewellyn Carole Lythall Carol Massey Helen McFarlane Michelle McNamee Mr K McKeown Walter Menzies Judith Mills J David Mitchell Rob Monaghan Jane Lesley Morris Maggi Morris David Owen Ruth Passman Jackie Patterson Rimple Poonia Tim Presswood Councillor Sue Proctor Ruth Pugsley Dr Judith Richardson Laura Roberts Paula Roles Dr Alison Rylands Mr John Sargent Dr Tariq Shah Ken Smith Mr D Soper Richard Speirs Jude Stansfield Penny Street Debbie Tasker Ged Taylor Mike Taylor Mike Travis Dr Jean Vickers Alex Villiers Cathy Warlow Julie Webster Dr Sheila Will Kate Williams Cathy Wynne

St Helens Primary Care Trust North Cumbria Health Action Social Services North West West Lancashire Primary Care Trust North West Universities Association Macclesfield Borough Council Northwest Development Agency Health Development Agency Northwest Development Agency Northwest Development Agency West Yorkshire Health Authority Trafford Youth Offending Team New Opportunities Fund Wyre Primary Care Trust Mersey Basin Campaign Preston Primary Care Trust Liverpool John Moores University Northwest Development Agency Wythenshawe Partnership Preston Primary Care Trust Vale Royal Borough Council Sure Start Parr, St Helens New Deal for Communities Team, Knowsley Manchester City Council North Manchester Primary Care Trust West Chester Regeneration Board Northwest Development Agency South Manchester Primary Care Trust North Manchester Primary Care Trust Cheshire & Merseyside Workforce Development Confederation Bebington & West Wirral Primary Care Trust Greater Manchester Workforce Development Confederation Primary Care Division, Trafford North Primary Care Trust Northwest Development Agency Wyre Primary Care Trust Carlisle City Council North West Mental Health Development Centre Sustainability Northwest Cheshire & Merseyside Workforce Development Confederation Cheshire West Primary Care Trust West Chester Regeneration Board Liverpool West Cumbria Primary Care Trust Halton Borough Council Sefton Primary Care Trust Liverpool Partnership Group Rochdale Primary Care Trust The Coalfields Regeneration Trust Department of Health

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Acknowledgements Conference organised by Sue Henry, Northwest Development Agency, in partnership with the Health Development Agency, the North West Regional Assembly, Government Office North West, the Department of Health and Social Care North West, and supported by New Start magazine Financial support and marketing by Northwest Development Agency Conference technical production by COMTEC Report edited by Andrew Hobbs and Dominic Harrison Published by NWDA Special thanks to Kath Reade for her unending enthusiasm and support for this agenda as a NWDA board member and now as chair of Cumbria and Lancashire Health Authority.

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