SUMMARY

—  The Mayor of London welcomes the opportunity to submit this written response to the Health Committee Inquiry into the contribution of the NHS to reducing health inequalities. In addition, he welcomes this government's focus on health inequalities as an issue which requires commitment and action from government departments, regional and local government, the health service and a range of other sectors and organisations.

—  The Mayor is concerned about inequalities between communities of place and those between communities of identity or interest. The impact of health inequalities on Londoners are described elsewhere. This submission is intended to supplement previously published evidence and research. Based on evidence, the Mayor is of the view that action to reduce health inequalities must focus on people living in deprived areas and those affected by relative poverty, as well as working with people disadvantaged by social exclusion, stigma or discrimination.

—  It is informed by preparatory work for the Mayor's Health Inequalities Strategy which included a Call for Evidence and an Outreach initiative, generating formal responses from more than 100 community groups and providing deeper insight into the factors affecting the health of London's more excluded communities. In addition, this submission reflects the priorities of a wide range of stakeholders—the London Health Commission, academics, NHS and public health practitioners, policy-makers, local government, community groups and employers—for strategic action to reduce health inequalities.

—  This inquiry is taking place at the same time as the Government is extending the Mayor's powers to include a new duty to promote a reduction in health inequalities in London and publish a statutory health inequalities strategy. In addition it coincides with consultation on NHS London's Healthcare for London. The Mayor considers it essential that proposals and action on these two strategic plans are aligned in order to achieve the maximum impact on the entrenched health inequalities that exist in London.

—  Reducing health inequalities must be a particular priority for NHS London, and the Mayor believes the NHS has a key contribution to make in each of the policy areas emerging as priorities for the London Health Inequalities Strategy, summarised below. In addition, the NHS has an ongoing role in supporting the development and delivery of the Mayor's strategies and programmes in a wide range of related areas, including those on economic development, spatial planning, environment issues, climate change, housing, and skills.

—  The submission summarises the Mayor's view about ways in which the NHS can contribute to reducing health inequalities both in its core role as a health service provider and in its broader role as an employer and corporate citizen. Additional evidence and information underpinning this summary is available on the Greater London Authority website.

INTRODUCTION

  1.  Average life expectancy continues to increase across the UK, and the outcomes for many individuals facing a range of health problems continue to improve, with the NHS having a central role in achieving this progress. However, an ongoing challenge facing health policy-makers and service providers is to ensure that those people who are most disadvantaged in health terms are benefiting most so as to reduce health inequalities as well as improving "average" population health.

  2.  In addition, a key challenge for the NHS is to place more emphasis on its potential impact on a wide range of social determinants of health through its role as an employer, procurer of goods and services, and estate manager. The health service can and should make a significant contribution to action on each of the emerging priorities for the Mayor's Health Inequalities Strategy which relate to income and employment, healthy places, individual and community participation, public service provision, and the continued building and application of evidence.

THE NHS'S ROLE AS A SERVICE PROVIDER

  3.  Access to effective health care, as well as social care and a range of other public services, can both prevent people becoming ill and help them recover when they do. Yet geographical variations in the provision of health services within London mean that some Londoners have better access to treatment and preventative services than others. Unequal access to health care information and services and differences in the quality of health care provision can both contribute to health inequalities and exacerbate existing disadvantage and exclusion.

  4.  The Mayor believes that the NHS should aspire to provide world-class health services to all their patients from all of their healthcare facilities. He considers the NHS must be world class not only at the level of hi-tech surgical or medical treatments and research, but also in the provision of community health services and preventative services, and in the contribution health services make to reducing inequalities.

  5.  The Mayor is concerned about the vulnerability of NHS funding for public health and preventative interventions, as illustrated by recent concerns about funding for sexual health promotion and HIV prevention in London. Similarly, he is currently discussing with government and other partners his concerns about the lack of clarity and certainty about arrangements for funding programmes to promote physical activity. Although the NHS is not the only sector to which this applies, it is important they continue to contribute to relevant initiatives to increase activity levels as part of a sustained effort to reduce future illness and premature death.

  6.  In response to previous Government consultations, the Mayor has emphasised key service-related issues he believes the NHS should address to improve the health of all Londoners, all of which are relevant to this Inquiry and include the need for:

—  significant and sustained investment and focus on prevention and health promotion within all care settings and across all NHS activity;

—  increased focus on supporting people to improve both their physical and mental well-being and to maintain or regain their independence;

—  proactive identification and planning to meet the particular needs of newly arrived, highly mobile, and excluded groups;

—  effective integrated health planning for new population growth, including investment in health and social infrastructure;

—  development and delivery of increasingly personalised, accessible, and culturally appropriate service responses;

—  increasing the diversity of the NHS workforce, and ensuring all staff are trained and supported to understand and appropriately meet diverse needs;

—  increasingly integrated care pathways, focussing on mental health challenges as well as physical illness or impairment, and better coordinated with other services including social care.

  7.  In addition, the Mayor has stressed the following points in response to Healthcare in London which are also of broader relevance to the NHS's contribution to reducing health inequalities:

—  support for the intention to shift much provision from hospital to community settings, with the proviso community services are accessible, high quality, and incorporate a comprehensive range of primary care services, including mental health interventions and health promotion advice and support;

—  the need for sustained efforts to tackle the "inverse care law" and shift the balance of NHS resources towards the most deprived areas and communities;

—  the importance of using effective, inclusive community engagement processes, including equalities impact assessments, to identify in detail the potential impacts of service changes on all the different groups that make up the affected population;

—  the need to further develop NHS commissioning capacity and to increase pan-London or cross-PCT commissioning to improve services for the most disadvantaged groups (eg homeless people) and those living with complex needs.

  8.  A wide range of the stakeholder and community groups involved in preparation of the Mayor's Health Inequalities Strategy confirm these as key issues to ensure the NHS maximises its contribution. In addition, several representatives of excluded groups report experience of a range of physical and/or attitudinal barriers to accessing health services. The Mayor urges the NHS to increase its focus on dismantling these barriers through appropriate performance management, staff training, and improved provision of language support and advocacy as well as ongoing investment in improving the physical accessibility of their services.

  9.  The Mayor believes action in all of these areas must be supported by well resourced arrangements for public and patient involvement. He is concerned at the loss of good-will and expertise resulting from the changes to relevant structures over recent years, and considers it essential for the NHS to invest in rebuilding community confidence and involvement in this critical aspect of providing public services. Actively considering the experience of communities, particularly those traditionally excluded from services, is a vital aspect of planning, delivering, evaluating and improving services.

THE NHS'S ROLE AS AN EMPLOYER AND CORPORATE CITIZEN

  10.  Traditionally the primary role of the NHS has been to respond to illness or impairment and to promote health. The Mayor welcomes the increasing emphasis on also recognising the importance of the sector's role in reducing health inequalities and influencing the wider social and economic determinants of health.

  11.  As a key employer, the NHS can make a major contribution to reducing health inequalities through action on income and employment. As well as having a significant influence on the health and well-being of its approximately 206 000 London employees, its influence reaches beyond its directly employed staff to thousands more working for its contractors and suppliers. The Mayor believes the NHS can and should work with him to further develop policies and deliver initiatives to:

—  reduce income inequalities by supporting initiatives to increase income for those in lower income brackets, such as implementation of the London Living Wage;

—  reduce worklessness by promoting access to employment, focussing particularly on the needs of those currently excluded from the labour market;

—  support parents and carers in the workforce by, for example, increasing the availability of flexible working, including quality part-time work, and affordable childcare;

—  increase the diversity of the workforce, ensuring a wide range of minority groups are able to access NHS-related employment opportunities including those most excluded such as refugees;

—  promote the benefits of "good" work through, for example, effective implementation of workplace well-being and anti-discrimination policies;

—  support other employers to invest in health and well-being at work, including initiatives to promote mental health;

—  improve the retention and in-work support for disabled people and those with mental or physical health problems;

—  facilitate early and positive return to work programmes for people excluded as a result of illness or impairment—both within and beyond the health service;

—  support ongoing investment in skills, training, and progression initiatives for all staff, including non-clinical staff members.

  12.  As the procurer of goods and services, and as the manager of a large estate and related facilities, the NHS also has an important role in delivering action on several other social and environmental determinants of health. Although identified with reference to London, action on the priority areas below is also likely to be an important aspect of the sector's broader contribution to reducing health inequalities in other regions through:

—  appropriate planning, location, design and construction of new facilities and the good management and use of existing facilities;

—  action on climate change and other environmental and sustainability issues, including "green travel planning" for their staff and patients;

—  identification and sharing of good practice on a wide range of issues related to health, well-being, and the reduction of health inequalities through action on wider determinants.

CONCLUSION

  13.  The Mayor welcomes the Health Committee's Inquiry into this important issue. Promoting physical and mental well-being and reducing health inequalities are key priorities for London. While significant programmes of activity have already been put in place to promote health, there is an ongoing need for more sophisticated consideration of the specific impact on groups disadvantaged by health inequalities. The Mayor remains committed to influence and support this, both through ongoing engagement with NHS London on their Framework for Healthcare, and through development and delivery of his Health Inequalities Strategy.

  14.  For more information on health inequalities in London, the Mayor would encourage the Committee to consider the range of reports published as part of the preparation of his Health Inequalities Strategy which are available at: www.london.gov.uk/mayor/health/strategy/reducing.jsp

January 2008