How can the North lead the way on health equity? Professor Margaret Whitehead University of Liverpool

Professor Margaret Whitehead (Chair), W. H Professor Margaret Whitehead (Chair), W.H. Duncan Chair of Public Health, Department of Public Health and Policy, University of Liverpool Professor Clare Bambra, Professor of Public Health Geography, Department of Geography, Durham University Ben Barr, Senior Lecturer, Department of Public Health and Policy, University of Liverpool Jessica Bowles, Head of Policy, Manchester City Council Richard Caulfield, Chief Executive, Voluntary Sector North West Professor Tim Doran, Professor of Health Policy, Department of Health Sciences, University of York Dominic Harrison, Director of Public Health, Blackburn with Darwen Council Anna Lynch, Director of Public Health, Durham County Council Neil McInroy, Chief Executive, Centre for Local Economic Strategies Steven Pleasant, Chief Executive, Tameside Metropolitan Borough Council Julia Weldon, Director of Public Health, Hull City Council

Life Expectancy: the North-South Health Divide Source: HSCIC, 2014

Kensington and Chelsea, London

Kensington and Fairfield, Liverpool Certain diseases – CVD, alcoholic liver disease, incidence increased at outset Risk of having disease is graded at the outset Risk of having most chronic diseases is determined by social class, but this is not the case with cystic fibrosis Most diseases the incidence varies with social class This represnets a profound differenc ein Life changes Many argue that these differnces are unfair, and furthermore there is nothing natural about them Consequence of how we organise society Wheter or not you get the disease does not depeind on SES

20 minutes on Merseyrail 10 fewer years of life expectancy Source: Barr for Due North, 2014

Building Blocks for Good Health The Health Divide in Darlington Building Blocks for Good Health Life expectancy (years) 2007-09 Pierremont Northgate 75 83 72 78 MEN: Highest 82 Lingfield Central 70 75 69 79 WOMEN: Highest 87 Town centre College Bank Top 77 81 Life expectancy better than Darlington average Life expectancy worse than Darlington average 69 78 Park West Lascelles Park East 82 87 76 79 Station 73 75 East meets west – the scale of inequality in life expectancy in Darlington Source: Davidson, M. DPH Annual Report 2013

Causes Differences in poverty, power and resources needed for health Differences in exposure to health-damaging factors Differences in opportunities to enjoy positive health factors and protective conditions that help maintain health, especially conditions that give children the best possible start in life

Why now? Threats and opportunities Austerity measures and poverty-generating welfare reforms hit disadvantaged areas and the North the hardest Demands for greater devolution to do things more effectively and equitably Transfer of public health to local authorities

DUE NORTH: LA cuts increase with increasing deprivation of area (IMD score) Source: Taylor-Robinson et al, 2012

Trend in child poverty and inequalities in infant mortality Source: Taylor-Robinson et al for Due North, 2014

Taylor-Robinson et al BMJ 2013;347:f7157

Two types of recommendations 1. What can agencies in the North do to help reduce health inequalities within the north and between the north and the rest of England? 2. What does central government need to do to reduce these inequalities? Lessons for the whole country, not just the North

DUE NORTH: actions to tackle root causes

Rec 1: Tackle poverty and economic inequality Northern agencies, working together: - Linking economic growth with public service reform to prevent poverty and promote prosperity - Promoting living wage - Joint spending power to promote good employment - Improving quality and affordability of housing

Rec 1: Tackle poverty and economic inequality Central government: Ensure national policies reduce debt and poverty: – Ensure welfare systems provide minimum income for health living (MIHL) - End in-work poverty through Living Wage -Develop a national industrial strategy that reduces inequalities between the regions - Develop policy to enable Las to tackle poor condition of housing stock at bottom end of private rental market

Rec 2: Promote healthy development in early childhood Northern agencies: Monitor and Increase proportion of overall expenditure allocated to giving every child a good start Ensure access to good quality universal early years education and childcare Maintain and protect universal integrated neighbourhood support for early child development, including Children’s Centres

Rec 2: Promote healthy development in early childhood Central government: Reduce child poverty through investment in: paid parental leave; flexible work schedules; Living Wages; promising educational futures for young women; affordable high quality childcare Reverse recent falls in living standards of less advantaged families Cumulative impact assessment of future welfare changes to mitigate negative impacts Increase proportion of overall expenditure allocated to early years Make provision for universal, good quality early years edication across the country

Rec 3: Share power over resources and increase influence of public over decisions Northern agencies: Deep collaboration across Northern agencies for a new approach to economic development and health inequalities Use greater devolved powers and resources to develop, at scale, locally integrated programmes to support people into employment Reduce the democratic divide: develop community-led systems for health equity monitoring, accountability, involvement in how local budgets are used

Rec 3: Share power over resources and increase influence of public over decisions Central government: Grant local government greater role in deciding how public resources are used to improve health of communities and greater flexibility to raise funds for investment on social determinants of health Allocate a greater share of resources to the places that need it most and to improve the lufe chances of the poorest fastest Invite LG to co-design and co-invest in national programmes, to tailor them more effectively to local populations

CCGs and other NHS agencies: Rec 4: Strengthen the role of the health sector in promoting health equity CCGs and other NHS agencies: Ensure procurement and commissioning maximises opportunities for high quality local employment and high quality care Work more effectively with Directors of Public Health and Public Health England to address risk conditions that drive health and social care system demand Support Health and Wellbeing Boards to integrate budgets and jointly direct health and wellbeing spending plans for NHS and Las Provide leadership to support health services and clinical teams to reduce children’s exposure to poverty and its consequences, and to reduce poverty among people with chronic illness