Creating Healthy Cities

This Kings Fund explored how local authorities, NHS and third sector organisations are working together to improve health and wellbeing in urban areas. It built on this excellent case study report. It was a great conference. The slides are here. My take on the 4 key points:-

1. Health or health care. We say “health and social care” when we mean “NHS and social care”

A lot of examples used focused on clinical care in the main, and NHS & Social care focused issues.

This comes back to the starting point & how people conceptualise “health”.

Many people talk “health” meaning the sector called “NHS”. We say “health and social care”, but then talk “NHS & social care”

We can talk health and social care, we must mean health and social care.

“health” can equate to “NHS”, but can also equate to “parks and green space” and “good air” and lots of other stuff.

Tricky point of narrative that one, but involves a far wider range of actors and systems than health care – green space, welfare, transport, economic growth, communities themselves, the activities of many private sector actors (jobs and economic growth etc / externalities of many private sector activities have health implications) etc. In this way “health” is not “NHS”, nor is it “state”.

Few, if any, of our leaders get the training to enable them to be multi lingual across this lot. People get trained in own tribe, then get thrown into bigger team and we never quite get out of the tribalism.

2. Why should we. What’s the point

Something to be said around one of the POINTs of getting better health, is of course to reduce demand on NHS, but downstream of that is social care demand (and our route to certain doom) but also maximising life chances and aspirations and all that. I know we all know this, but worth reminding ourselves often that those bike lanes, parks, leisure services, welfare rights advice services have more than a fluffy social purpose etc but can quickly track back to harder edged demand.

The point of health in all policies?

I wrote a little on why is it in the interests of a city to exercise power and spend resources on generating better health – making good on the health in all policies aspiration and really meaning it has economic, social justice and direct impact on demand for services.

This quickly gets back to language and definitions. The public and media think health = NHS, most think public health = drains. See point 1.

This explains many people’s enthusiasm for population health (tho that often gets based in an NHS paradigm).

3. The powers cities actually have

The session from Sonia Angel NYC was a highlight, on the role of their Board for Health (Im figuring akin to a Health and Well Being Board). It has some interesting powers. In NYC, If National Govt isn’t going to do anything local Govt can take power in responsibility for addressing a risk to health.

In U.K. opposite is in place. Maybe THIS is the key power to ask for devo wise, the power to take action if no other government body is prepared to, there is a political and democratic mandate to, and its legal (the 2000 duty to promote well being is pretty broad).

It may be worth spending some time to understand more about who has what powers – legislative and regulatory. In UK local government has huge body of regulatory and legal weight behind it, & powers that often we forget about. Powers permit Local Govt to do things, lawyers have insight into what can be / can’t be achieved. Councillors – esp cabinet – allow powers to be executed. Public views matter, a lot. Consider how best to shape public views who will be interested in potholes in road and dig fouling. We will all chose the here and now, so ask specific questions.

Many of the powers are present already through existing regulations and legislation. PH wise mostly is about delegated competence for infection and food poisoning but couched in terms of “protection of health”. Many of the powers are present already through existing regulations and legislation, which apply to infectious disease from decades ago, but framed in such a way that can be applied to non communicable diseases.

(it’s worth saying that resourcing wise, NYC had 6,000 people working in PH dept – see Saving Gotham – accepted its a bit different, we’ve got about 20).

There are two ways of testing the use of a cities powers. Firstly collect examples of where different authorities have stretched themselves in the use of their powers and test to mechanics of why and how that happened. Secondly, go back to the legislation and form a view on what is legally possible, especially related to the 2000 duty to promote wellbeing. There are many with a view that cities underuse the powers they already have.

People change, institutions don’t. Thus get the mission written into the mission of the city institutions.

How are people organised, how do we change the rules to focus on ensuring the right thing happens, ensuring we get the narrative straight, ensuring that the CITY – and its institutions, actors and systems see addressing inequalities as part of something that’s mission critical for their business, in a language & currency that is meaningful and tractable to them.

The key one for me is the general power of competence

…..the local authority can do anything to promote the social, economic and environmental wellbeing of the area, apart from raising taxes and anything that isnt reasonable……

Also have a look at government DCLG ( now MHCLG) research into the old wellbeing power’s use and barriers. Practical use of the Well-Being Power

(All c/o @HiPNetworkUk)

4. How to make the mission of inequalities mission critical

The climate may be changing. Inclusive growth could be characterised as health inequalities in disguise, and vice versa. Ditto inclusion health. There may be overlaps, and clear space but there is a lot of convergence. NHSE are seemingly gearing up for a renewed attack on inequalities from a clinical and single disease focus area. Downstream is equally necessary, and needs to be linked to whole population and social policy oriented interventions taking an inequalities approach.

Just some thoughts on an excellent meeting.

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