HEALTH INEQUALITIES IN GREATER MANCHESTER

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1 GMCVO s briefing on areas of policy, practice and the operating environment affecting the voluntary and community sector in Greater Manchester 4 HEALTH INEQUALITIES IN GREATER MANCHESTER The role of the voluntary and community sector Greater Manchester is in very poor health. Rates of obesity, smoking, cancer and heart disease are significantly higher than the national average and life expectancy at birth is the lowest in England. Perhaps more starkly, within Greater Manchester itself, there is a gap in life expectancy of almost six years between the poorest and most affluent areas. What can be done to combat this? Over the past twelve months or so, the Audit Commission, a national auditing body that exists to ensure public money is effectively spent, has undertaken an extensive review of health inequalities right across the subregion, working with a wide range of partners with a stake in this agenda. Its aim has been to assess the current situation, taking note of what is working well and what could be improved, and produce a strategy to ensure a united and coherent approach to reducing health inequalities. What role for the voluntary and community sector (VCS) in all this? GMCVO has held a seat on the Audit Commission s steering group since the review began - to help analyse current activity in the sector and to explore how this can be expanded. A number of workshops have been held looking at commissioning and partnership working between the statutory and voluntary sector; the findings from these will inform the final report, which is due to be published this January. Its likely recommendations will be discussed in more detail later on. Let us be in no doubt: the third sector is increasingly relevant to the fight against health inequalities. Much of the work it does is about prevention and working closely with local communities; it is about education, diet and lifestyles; it is about winning hearts and minds. The idea that public health can be improved by the NHS, and the NHS alone, is moribund. It must use its partners, and its resources, imaginatively if it is to succeed in reducing health inequality. Over the next few pages there will be more discussion on health inequalities and a closer look at the existing data on public health in Greater Manchester. There are contributions from some of the key VCS players in the sub-region as well as analysis from the Audit Commission and the Association of Greater Manchester Primary Care Trusts on how they see the role of the sector developing - as the drive to tackle health inequalities continues.

2 Involving the voluntary sector in tackling health inequalities People in Greater Manchester can expect to die earlier than others in England. Life expectancy in certain communities can be six years lower than in others. Many people can also expect to suffer from chronic illness in later life. Whilst there is a general improvement in life expectancy, the gap continues to grow. In recognition of this state of affairs, the Audit Commission carried out a review of health inequalities in Greater Manchester last year. Nigel de Noronha describes how the voluntary sector was involved in the process The Audit Commission identified health inequalities in Greater Manchester as a focus for our work in 2005 and, in an unprecedented review, worked with appointed auditors KPMG and PWC to engage with the 40 statutory organisations with a direct interest in addressing the issue. We also engaged with GMCVO to enable us to ensure the voice of the voluntary and community sector was represented. We developed an initial assessment of the issues facing Greater Manchester in phase 1 of the review which was carried out between November 2005 and February We spent the next few months presenting these messages to a range of organisations and partnerships and designing a workshop programme for phase 2 of the review. In phase 1 our engagement with the voluntary and community sector highlighted the need to develop consistent approaches to joint working between the statutory and voluntary sector, and to ensure that these arrangements reflected a more equitable approach to partnership. In designing phase 2 we were concerned to ensure that organisations representing the variety and richness of the third sector were able to contribute to creating the environment for change we had identified was required to address health inequalities. Working with GMCVO we held a successful workshop for the sector in September 2006 where speakers outlined how commissioning in the NHS works. Workshop sessions then developed a number of potential actions to improve the way statutory organisations work with the sector to address health inequalities. Colleagues from the third sector have also contributed to other workshops. A mental health workshop held on the 17th October had a session dedicated to engaging with the voluntary sector in the field of mental health, and at the end of the month colleagues attended a workshop on the role of non-executive directors and members. GMCVO presented to the workshop on corporate citizenship in the NHS ensuring our organisations are socially responsible by using corporate powers and resources in ways that benefit rather than damage the social, economic and environmental conditions in which we live. How public sector organisations behave - as employers, purchasers of goods and services, managers of transport, energy, waste and water, as landholders and commissioners of building work and as influential neighbours in many communities will make a big difference to people s health and to the well being of society, the economy and the environment. Seeking cost reductions through a mixed economy of service providers should be one of our aims, but if it leads to local firms or voluntary organisations being pushed out of business, we have to ask ourselves whether value for money is compatible with the drive for sustainable local communities. Michael O Higgins, Audit Commission Chair, speech to New Local Government Network, 7th November 2006 On 7th December an event, Health Inequalities in Greater Manchester Everybody s Business, was held at the City of Manchester Stadium. This event saw the launch of the Healthy Communities Improvement Partnership and a series of presentations setting out key actions that will continue to address the health inequalities gap. We will outline the actions required as a result of our review at the event. Whilst we are still discussing the proposed actions, we would expect them to include: investing in the capacity of the voluntary and community sector to engage with local strategic partnerships, to advise on addressing health inequalities, and, to develop the collective knowledge within the sector; 2

3 making the commissioning process more transparent and addressing barriers facing the third sector in securing contracts to deliver services; ensuring regular structured communication to keep the sector informed on plans, strategies and priorities. For further information, contact Nigel de Noronha, Audit Commission, 7th Floor, Regent House, Heaton Lane, Stockport SK1 1BS. n- About the Audit Commission The Audit Commission is an independent body responsible for ensuring that public money is spent economically, efficiently and effectively, to achieve high-quality local services for the public. Its remit covers around 11,000 bodies in England, which between them spend more than 180 billion of public money each year. The Commission s work covers local government, health, housing, community safety and fire and rescue services. As an independent watchdog, the Commission provides important information on the quality of public services. As a driving force for improvement in those services, it provides practical recommendations and spread best practice. And as an independent auditor it monitors spending to ensure public services are good value for money. The commitments The Audit Commission review has acted as a catalyst for strengthening the existing relationships and enabling a clearly articulated and shared approach to the delivery of improved health across the conurbation, says Marilyn Simpson of the Association of Greater Manchester PCTs. And the agencies intend making a pledge to cement their commitment to working together to deliver solutions to health inequalities Greater Manchester is a complex conurbation, which adds to the challenge for both statutory and voluntary organisations, with 14 (now merged into 10) PCTs, 10 local authorities and local strategic partnerships, 4 mental health providers, an ambulance trust, a new Regional Strategic Health Authority, 7 acute/specialist trusts and three new foundation trusts. It is recognised that there are many other agencies outside the statutory field that will play an increasingly important part to improved outcomes including private, community and voluntary agencies; therefore we need to ensure that all partners are fully engaged and can realise the vital contribution that can be made in addressing inequalities across the county. These contributions along with specific recommendations from the Audit Commission were presented at the health inequalities event in Greater Manchester on 7th December. Organisations at the event committed to improving health inequalities by signing the following pledge: We believe Greater Manchester is not as healthy as it could be or should be. Despite significant effort and some improvement in life expectancy, the burden of ill health and premature death suffered by the people of Greater Manchester in comparison with the English average is unacceptable. We will support the population of Greater Manchester in improving their own health and in holding to account the range of statutory, voluntary and commercial partners that serve Greater Manchester for their contribution to improving life expectancy and reducing health inequalities. We believe it s about all of us working to create a culture of promoting health through improved health services but also through improvements in the environment, crime, housing, open spaces, our schools, our transport system, in our communities, and through employment. We commit to redoubling our efforts to work closer together and through our individual efforts, the application of our shared assets, resources, expertise and commitment, and with the genuine commitment and engagement of the people of Greater Manchester, we will together create a conurbation that is not only vibrant and prosperous but healthy. Improving the health of the population of Greater Manchester is everybody s business. Marilyn Simpson is Project Director at the Association of Greater Manchester PCTs. Tel: Marilyn.Simpson@alwpct.nhs.uk 3

4 Community health profiles People in the North West of England have significantly lower levels of health than the national average according to data collected by the Association of Public Health Observatories. Health profiles for all but two of the 388 local authority areas in England, show that the NW region fares badly in 18 out of 25 measures of health. The measures used in the survey the results of which were published in April 2006 include indicators such as smoking, binge drinking, obesity, life expectancy, drug misuse treatment, children s tooth decay and crime. There were only two indicators in which the North West did better than the national average: older people supported at home and mental health treatment. The North West has the highest incidence of alcohol-related hospital stays and of people receiving treatment for drug misuse, and is the second worst region for binge drinking (after the North East) and violent crime (after London). It is also the second worst region for deaths from smoking and early deaths related to cancer and circulatory disease. The Health Profiles, which have been commissioned by the Department of Health Public Health Information and Intelligence Task Force, can be used by local authorities and the health service to highlight the health issues for their local authority area and to compare them with other areas. The profiles are designed to show where there are important problems with health or health inequalities. They can be used with other local information, such as the Audit Commission's Area Profiles, to target action to improve the health of local people. It is also hoped that they will be used for action planning by local strategic partnerships. The profiles will be updated annually. Full details of the health profiles for all local authority districts can be seen at: Health profiles for six indicators in the 10 districts of Greater Manchester Indicator Area Deprivation (%) (note 1) Life expectancy fem/male (years) Obesity adults (%) (note 2) Smoking (%) (note 2) Binge drinking (%) (note 2) Drug misuse treatment (per 100k) (note 3) England / North West / Bolton / Bury / Manchester / Oldham / Rochdale / Salford / Stockport / Tameside / Trafford / Wigan / Figures in bold show the worst area for each of the six indicators. 1 Percentage of people in this area living in the 20% most deprived areas of England. 2 Synthetic estimates derived from the Health Survey for England. 3 High rates considered worse as reflects high prevalence. 4

5 Grow your own Against the background of the Audit Commission s review of health inequalities, Mike Wild explores the voluntary and community sector s role in tackling wellbeing but says that if the sector s role is to grow it will need to be fed The Audit Commission has been reviewing Greater Manchester s progress in tackling health inequalities.and the results are not good. To be fair, it s a huge and unwieldy challenge: Greater Manchester has the some of the worst health and wellbeing in England. In Manchester, life expectancy is roughly ten years less than in the south east and when you look behind the statistics, the picture gets worse: research is suggesting that people in the area grow older more rapidly: even within Manchester there s a physiological age gap of up to 15 years between some communities, so a person of 50 would be likely to have the same general level of health as someone aged 65. Across the country, mental ill health is more common than asthma and in Greater Manchester we have levels of need similar to the most deprived London boroughs. The Audit Commission s findings highlight problems with the systems which are attempting to address these issues. The approach has so far focused on public health networks between NHS Primary Care Trusts: aiming to co-ordinate efforts and share learning and resources. One of the problems, however, is that these networks are usually driven by the Directors of Public Health in each area. The Commission identified a lack of overall leadership: not because of a lack of commitment from professionals but because the job descriptions of Directors of Public Health are too broad. They cannot focus in the midst of so many competing priorities. For example, they spend much time on the relatively small amounts of flexible funds which become available in the system and little on the much more significant mainstream budgets. The upshot is a situation where those with a strategic lead have to choose between hanging and flogging offences: concentrating only on targets which Government will come down on them most heavily for failing to achieve. It s important to remember the background for all this: Derek Wanless report on the future of health services said that the only way to make the NHS viable in years to come was to reduce need and that means promoting good health in all communities. And that s precisely where the voluntary and community sector fits in. The voluntary and community sector is about addressing inequalities: we do things because there s a need or an issue which nobody else seems to be tackling. Broadly, we re good at engaging with people the mainstream services see as hard to reach. We also have strengths in being much more flexible: voluntary sector services are often able to respond more easily to the person as an individual. Statutory agencies have expertise and technical skills but this is achieved by responding to the condition rather than the complex mix of conditions and how they shape a person s life. Effectively, we end up with the usual relationship between the sectors: both working on the same problem in our own ways but not really joining forces. Increasingly, central Government is trying to drive partnership working but their approach is a shotgun wedding, placing requirements (ie more targets) on commissioners to work with and make use of the skills of the voluntary and community sector in the hope that everyone will eventually live happily ever after. Commissioners therefore come under pressure to follow the quickest and easiest solution: engage with voluntary sector organisations that are best able to be commissioned. The trouble is that this isn t necessarily the same thing as organisations that have the best impact. It s a mistake often made in job interviews: do they test your ability to do the job or your skill at giving interviews? One of the main results of the Audit Commission s report, therefore, is likely to be a greater emphasis on engagement with the voluntary and community sector. It remains to be seen how realistic this is: most of the groups who struggle to engage are small and medium sized organisations that simply don t have the capacity to raise their eyes from the day-to-day business of delivering services and surviving. The voluntary sector already plays its part in tackling inequalities. However, this role cannot develop further in the current system: the groups involved are too unstable and the ones with the greatest social capital are often those with the least financial stability. Commissioning processes need to be designed to address this issue. The voluntary and community sector is resilient and will continue to exist, but if you don t feed it, you can t expect it to grow. Mike Wild is director of the Manchester Alliance for Community Care More information about the work of MACC can be seen at: 5

6 The BASIS for tackling health inequalities in Salford Neil Walbran outlines how a third sector-led health forum is developing collaborative ways of working to address health inequalities in Salford It s almost three years since Salford s Primary Care Trust finalised its own Health Inequalities Strategy and started to implement programmes of health improvement to narrow the gaps for Salford s community. Initially, a Healthy City Forum was established to oversee work, and the third sector was represented at the Forum by the chief officer of Salford CVS. The creation of a Health and Well- Being Sub-Group was the chosen path to community involvement and where the third sector was strongly represented. At an initial meeting, with over 25 organisations represented, the Health Inequalities Strategy was presented and we were asked to come up with ideas for collaborative work which would address health inequalities under the identified priorities. Unlike our statutory partners, the third sector rarely develops over-arching strategies for health and then produces action plans from these. Voluntary and community groups doing work that fits neatly into place with regional health directives rarely occur. Work in our sector around health, certainly in Salford, begins when a group of local people sometimes two streets big - are motivated enough to pick up the tools of governance and set about changing things for the better. So our sub-group came up with some great ideas for addressing health inequalities but which group would be willing to house them? How to resource them? Progress was stymied at this point. As a response to this, and in an effort to build some cohesion around health in our sector, Salford CVS set up BASIS. BASIS is the Health and Social Care Forum for Salford s third sector. Its aim is to improve the capacity for clear and representative voluntary and community sector involvement in the decision making structures within the city around health and social care. Now in its third year, BASIS has set its priorities for action through an extensive consultation process with the sector. Unsurprisingly, they are based around communities with identified health initiatives attached to them. The challenging role of BASIS is to provide an interface between the target-led strategies in the statutory sector and the community-led initiatives in our sector. I have handed over the reins of BASIS to Suzy Farrow, who is the new Development Worker for Health and Social Care at Salford CVS. She can be contacted on or at suzy.farrow@salfordcvs.co.uk Neil Walbran is Procurement Co-ordinator at Salford CVS For more information on health and social care partnerships in other areas of Greater Manchester please visit: Health and Care Together, Bolton CVS: spx?groupid=592 Wigan and Leigh Council for Voluntary Service: Manchester Alliance for Community Care: Community Network for Manchester: Voluntary and Community Action Trafford: Rochdale CVS: < Bury CVS: < Stockport CVS: Health and Social Care Team, Tameside Third Sector Coalition: Voluntary Action Oldham: 6

7 Addressing health inequalities in BME communities Val Bayliss-Brideaux looks at how the Black Health Agency is tackling the health needs of black and minority communities in Greater Manchester There are several key reasons why black and minority ethnic (BME) communities experience health inequalities. First, existing services have not recognised the different needs of diverse groups of people. Black and ethnic minorities have specific health issues that are not adequately researched or understood by mainstream health and social care providers. Secondly, in receiving health and social care BME communities experience a lack of culturally appropriate techniques of care. Such lack of awareness, results in disaffection with services or an unwillingness to access them in the first place.* Historically, BME communities have been housed in deprived and marginalised areas (often inner city) where health service provision has been poor and patchy. This is another factor in preventing equal access to healthcare. The Black Health Agency is a charity dedicated to improving the lives and changing the futures of BME communities. We support and enable people to improve their health and well being through a range of unique services. BHA has been at the heart of developing culturally-aware services since We deliver client services such as the African AIDS Helpline, which is a national service, providing free confidential and multi-lingual advice on HIV/AIDS and sexual health to Africans living in England. ARISE HIV Support Project provides face-to-face support, welfare and advice to BME men and women living with, or affected by, HIV/AIDS in Greater Manchester. BHA also uses innovative community development models to work with hard to reach communities, such as young black men and unaccompanied refugee and asylum seekers, through its Young Black Peerspectives Project, which employs young black people as peer educators to work with their peers on health well being. Through peer education techniques, young people gain skills, knowledge and experience on issues that are relevant to their lives, including sexual health, selfesteem, employment and education. Jeena Health has built a strong relationship of trust with South Asian women in Manchester, Salford and Trafford on health issues relevant to South Asian women. Culturally sensitive, up-to-date and effective. It is accessible to women of all ages who need information on health issues or one-to-one support. Project Jeena supports young Asian women who are worried about pregnancy, contraception and parenting, as well as offering support to their partners and families and helping them to make informed choices. By in-depth assessment of community needs, Jeena develops and implements effective strategies to raise awareness of health issues. Reaching Out is a new project which enlists people from the within the BME communities themselves to be trained and skilled to deliver drugs and alcohol awareness training within their own communities. A key aspect of our work is advising agencies on implementing equality and diversity strategies, and ensuring that service delivery and action planning meet the needs of diverse communities, and that equality and diversity is embedded in organisation s outlook. This work is a major part of the work of Manchester Race and Health Forum and Manchester Drugs and Race Unit. A key role of the voluntary sector lies in its ability to connect with BME and other marginalised communities, both in terms of its established relationships with, and its knowledge of health issues and key needs of, such communities. With public bodies obliged to conduct race equality impact assessments for service delivery, and to incorporate equality and diversity into their structures, polices and day-to-day practice, the need for partnerships with community agencies able to provide the awareness and knowledge able to fulfil this will become vital. The Government wishes to see much more strategic partnership work developed between the VCS and statutory health sector and if implemented fully, this should benefit BME voluntary sector organisations. As Mike Farrar, Chief Executive of NHS North West, commented at the Race for Health conference held in Manchester in November 2006: It is imperative that major commissioners see the health needs of BME people as an integral part of their work and not an add-on. The Audit Commission s finding that little work had been done to address health inequalities can only be overcome with such a realisation. * source: 'Delphi' Survey of Priorities in Ethnicity & Health Research and Evidence, Centre for Evidence in Ethnic Health and Diversity 7

8 Central Government s drive to tackle health inequalities The Health Inequalities Unit (HIU), based in the Department of Health, is tasked with reducing health inequalities in health outcomes by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth: Life expectancy: a 10 per cent reduction in the relative gap in life expectancy at birth between the fifth of areas with the worst health and deprivation indicators and England as a whole. Infant mortality: a 10 per cent reduction in the relative gap in infant mortality rates between routine and manual socio-economic groups and England as a whole. The root causes of health inequalities are, of course, numerous and complex. Social exclusion, poor housing, low educational achievement, unemployment and homelessness are just some of the contributory factors. Increasingly, the Government is looking to address health inequalities in many different policy areas and across departments. For example, local authorities are now assessed on the action they are taking in this area. Councils are encouraged to use Local Area Agreements (LAAs) and Local Strategic Partnerships (LSPs) to set out plans to tackle health disparities, in partnership with PCTs and the local voluntary and community sector. What s more, through the Communities for Health (C4H) initiative, hundreds of thousands of pounds have been spent on projects dedicated to tackling health inequalities in their locality. Realistically, the Government is unlikely to meet the above targets. More work needs to be done and investment is needed. The recent Audit Commission review has noted this in our subregion and urged Greater Manchester to act. For more information on the health inequalities agenda and to find out opportunities to get involved, please visit the sites listed below: Government Departments Department of Health: Health Inequalities Unit ealthinequalities/fs/en Children and Young People's Unit (CYPU) Department of Culture, Media and Sport Department of Communities and Local Government Social Exclusion Unit Office of the Third Sector (Cabinet Office) Other useful links Northwest Strategic Health Authority Communities Online Community Development Foundation Community Matters Health Action Zones on the NICE website Health inequalities on the NICE website Health News Information for Local Government from Central Government Joseph Rowntree Foundation King's Fund Public Health Observatories Greg Crouch Access Network Officer, GMCVO ISSUES is produced six times a year by GMCVO. It is compiled and edited by David Sutcliffe (david.sutcliffe@gmcvo.org.uk, ). GMCVO is the voluntary and community sector infrastructure organisation for the sub-region of Greater Manchester. It aims to strengthen the voluntary and community sector, build bridges with other sectors, and influence local and national policy. GMCVO s work involves representing, promoting and developing voluntary and community organisations, and working in partnership with local, regional and national infrastructure. GMCVO is also the sub-regional lead body for ChangeUp. GMCVO, St Thomas Centre, Ardwick Green North, Manchester M12 6FZ. Tel: Fax: gmcvo@gmcvo.org.uk GMCVO is a Registered Charity no and a company limited by guarantee no GMCVO is grant-aided by AGMA (the Association of Greater Manchester Authorities). November/December 2006

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