Aligning health and local government incentives

Co-ordinating work between health and local government to address health inequalities is increasingly seen as a major element of progress. Health Inequalities: progress and next steps highlights the crucial role of local government in tackling health inequalities. Local government provides leadership and the structures within which citizens can make their voice heard. It can support advocacy for those who struggle to be heard, it can understand the needs of its citizens beyond those for healthcare and meet those needs in a way that drives down inequalities.

Just as important, local government is responsible for many of the services that have a vital role to play in tackling health inequalities: housing, environment, schools, crime and disorder, and regeneration. Ruth Hussey, regional director of public health for NHS North West strategic health authority, describes the positive response of local government to their joint work in the North West as "overwhelming. The level of buy-in to the joint health and social care indicators for local area agreements has been phenomenal".

She admits that the work can be "very challenging, but on the whole, people recognise the health inequalities our local population are facing, and have taken leadership very seriously".

Joint approach

As the area is building on its joint strategic needs assessment there are now many more joint directors of public health emerging across the sectors across the patch. Dr Hussey thinks the progress has happened because "people see the interconnectedness of the economy: lifestyles, choices and outcomes all play a part. So we need a joint strategic approach. And I've been very encouraged by how people want to address this within the confines of locally available tools."

How has the Improvement and Development Agency helped to align and complement this plan? Dr Hussey sees IDeA as a way of "helping local government and partnerships assess what and how they're doing. Feedback from IDeA to the local authority and partners has been constructive in setting out areas for improvement".

Clear direction

Has IDeA proved a powerful tool? Dr Hussey thinks that from a local government perspective, its work complements the requirements of the Office of the Government Regulator "to want to know what to do better and be committed to doing it. People must have local ownership, or it won't work".

On the role of inspection and regulation, she feels that the current mix of incentives, policy, evidence and clear direction is having an impact.

"The Healthcare Commission had some very helpful questions to ask of providers about what they do to promote the health of their local community and staff. The set of incentives and levers for care quality need to be developed. Health inequalities are not just about the wider social determinants and context, they're also about the disadvantaged getting high-quality care every time, so inspection and regulation for health and local government should support this agenda.

"On aligning incentives, we've been speaking to Audit Commission staff who are keen to look at our Comprehensive Area Assessment. It's not only about 'is this locality creating good health?' but 'are services delivered in such a way that the poorest get good access to good services in health and education?'"

Investment patterns

Dr Hussey also recognises the importance of tracking investment, investing in the right things and matching patterns of need, but she acknowledges that public health spend can be hard to measure: "In health inequalities, it includes spending on social infrastructure, lifestyle and social environment.

"In areas like cardiovascular disease, we need to look at what we're spending on promotion and prevention locally, balanced against outcome measures. At SHA level, we can compare mortality rates with investment against the problem. Sometimes there are good reasons for a mismatch, but we have to measure it and then interpret. There's no single definition of prevention: we must develop this area to improve provision."

Dr Hussey feels the shift in perspective towards more prevention "means we must invest more in a well-trained workforce and in supporting people in prevention, so that every encounter with the NHS is orientated to prevent disease progression. In social care and housing, it would be about considering prevention of falls.

"They may do this already, but we need to ensure that it's systematic, and that people know the key messages. It's got to be supportive and preventive."