ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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The Mayoral Health Commission ALL CHANGE - the platform to a healthier Liverpool
Contents
Members of the Commission and Local Commission Steering Group 2
Foreword 3
Conclusions, Recommendations and Way Forward 7
1. Overview of Liverpool 13
2. The Mayoral Commission on Health 19
3. The City of Liverpool’s Assets and Resources 21
4. Findings 27
A common agenda
What the vision needs to be
The Factors
The People of Liverpool
Prevention and health promotion
Integrated care
Incentives
Organisations to deliver the plan
Workforce and skills
A healthy economy
Evidence and research
Technology and health
5. Summary of Recommendations and Way Forward 43
6. References and additional sources 49
Appendix A: Method of working and gathering the evidence 50
Terms of reference
Those who attended meetings and gave oral evidence
Appendix B: Commission questions 54
Appendix C: Those providing written responses to the Commission’s 56
consultation questions
Appendix D: Glossary 57
Aknowledgements 60
Report of the Mayoral Commission 1
Members of the Commission
Professor Sir Ian Gilmore (commission chairman)
Dr Susan Shepherd (commission secretary)
Dame Christine Beasley, Chief Nursing Officer for England, 2004-2012; Vice Chair, NHS Trust
Development Authority; Chair, Health Education North Central and East London
Foreword
Professor Dame Carol Black, Principal, Newnham College, Cambridge; Expert Adviser on Health
and Work to the Department of Health England and Public Health England
Professor Sir Alasdair Breckenridge, Chair, Emerging Science and Bioethics Advisory Committee
(Department of Health); Emeritus Professor of Clinical Pharmacology, University of Liverpool
Sir Cyril Chantler, Chairman, UCLPartners, Academic Health Science Partnership It is undoubtedly a challenge in challenging times to produce a report on the future of health
Martin Else, Chief Executive, Royal College of Physicians (to Sept. 2013) and healthcare in the city of Liverpool when resources are being withdrawn from local authorities
Professor Chris Ham, Chief Executive, The King’s Fund and NHS funds are at best capped at current levels. However, it did not feel that way because,
Sir Robert Lechler, Vice Principal, King’s College London; lead King’s Health Partners, DH without exception, all parties from whom we took evidence agreed that the task was important,
accredited Academic Health Science Centre indeed essential and urgent, and expressed willingness and enthusiasm to embrace radical
change. Hence, the importance of using the ‘burning platform’ as the metaphor came
Professor Sir Michael Marmot, Director, UCL Institute of Health Equity
through strongly. This came from all sectors, including public health, social services, primary and
David McDonnell, President of Council, University of Liverpool; formerly Global Chief Executive, secondary care, voluntary organisations and, most importantly, patients.
Grant Thornton
Molly Meacher, Baroness Meacher of Spitalfields, House of Lords We have produced ten recommendations – a ’10-point plan’- the first three being overarching
Sir Hugh Taylor, Chairman, Guys and St Thomas’ NHS Foundation Trust principles and the remainder how these might be achieved. Now the challenge is to take
these ten recommendations of the report and mobilise the enthusiasm that we experienced to
bring about practical change. This will require some new partnerships and a fresh start for some
existing ones. We start from a position of strength, for example, with strong primary care organised
around neighbourhoods and some world-class bioscience. We have a Clinical Commissioning
Local Commission Steering Group Group with a strong vision, expressed in ‘Healthy Liverpool’, that puts well-being and prevention
of disease at the centre of its plans. However, we have to acknowledge also that we have some
Professor Mark Bellis, Immediate-past Director, Centre for Public Health, Liverpool John Moores of the poorest health outcomes and widest health inequalities in the country. We have new
University; currently Director of Policy, Research Development, Public Health Wales opportunities to tackle these as public health now forms an essential bridge between health and
Gideon Ben-tovim, Chair North West Coast Academic Health Science Network; social care, between local authority and NHS.
former chair NHS Merseyside
I appointed commissioners largely from outside the city, in part to bring their experience from
Dr Simon Bowers, General Practitioner; and Deputy Chair, Liverpool Clinical Commissioning Group
other parts of the country to us and in part as national advocates on our behalf so they might
Dr David Fearnley, Medical Director, Mersey Care NHS Trust join us on the important journey that Liverpool is embarking on. I am grateful to them for their
Dr Craig Gradden, Medical Director, Liverpool Community Health NHS Trust time and effort. I am also grateful to the local steering group, which comprised hard-working
Professor Ian Greer, Executive Pro-Vice Chancellor, Faculty of Health & Life Sciences, local professionals in the field, for being so generous with their time and expertise. Finally, I am
University of Liverpool grateful to the Mayor, Joe Anderson, and his team for setting me this challenge and giving me
Dr John Hussey, General Practitioner; and Medical Director, NHS England (Merseyside) an opportunity to leave this proud city, which I have served as a hospital doctor for more than 30
years, with a legacy that should deliver better health and wellbeing for its citizens for decades to
come.
Report of the Mayoral Commission 3
Conclusions, the widely expressed view from witnesses that
something radical must be done, and that they
Recommendations and their organisations are ready and willing
participants in this, leaves the way clear for
and the Way Forward change.
Conclusions But minor modifications in the existing
healthcare system will not be enough to meet
In 2012 the directly elected Mayor of Liverpool, the challenges Liverpool faces. The city must
Joe Anderson, invited Professor Sir Ian Gilmore use the current ‘burning platform’ to bring
to lead a Commission to determine how best about the radical shift required. Inevitably, this
to support and improve the health and well- will create tensions and there will need to be
being of the people of Liverpool. After a year resolution of some key issues before any plan
of wide-ranging consultation and subsequent can be put into action, let alone accomplished.
analysis of the information gathered, this
work is complete. The result is this report: the One of Liverpool’s strongest assets is its human
conclusions are set out below. capital, and it is famous for its community spirit
and resilience. However, there is also a culture
As a city Liverpool has made major of over-reliance on hospitals for all medical
achievements in the last 20 years in the areas treatment. To effect the changes required, this
of urban and economic regeneration. It has attitude to healthcare will need to be changed
exceeded public health targets and narrowed and the people of Liverpool will have to have a
some measures of heath inequalities: and it has greater awareness of the range of alternatives
been left a strong primary care legacy by the to hospital, which in their turn need to be more
PCT. However, Liverpool shares the national and accessible, including over the 24/7 period.
international challenges of delivering ever-more
expensive specialist care through new drugs and People need real practical support to be able
other technologies at a time when people are to live more independent and healthier lives.
living longer, working and paying higher taxes for Grasping the importance of self-determination
a shorter part of their lives, and are developing with respect to health and well-being, and
the degenerative co-morbidities of longevity. then acting on it, is governed by factors well
outside the remit of the NHS: factors such as
The city also has particular challenges, despite poverty; educational attainment; employment
the success of its public health programmes, as prospects; family cohesiveness; and a general
it remains at the bottom of the league for most investment in life that often only comes with
indices of deprivation, and many of its citizens being fully engaged with society in a positive
have a history of poverty, unemployment, and and meaningful way. Change cannot be
social exclusion. As a city Liverpool has been achieved without the commitment and
particularly badly hit by cuts in central funding understanding of the people, and those
for social services and for local government engaged in commissioning services and
and will be disadvantaged further if proposed providing care will need to recognise the
changes in the formula for allocation of health breadth of issues they will be dealing with.
and social care funding favouring age over
deprivation are introduced. So, although there Specialist staff will continue to require specialist
are many successes to build on, there is a sense education and training and there will be a level
that the finishing line recedes faster than the city of professional expertise in all the partnering
can run. organisations that can only be acquired
through time spent ‘in post’ working with staff
From evidence put before it the Commission who have gone through similar education
concludes that there is sufficient willingness to and training. However, the people receiving
participate, expertise, experience and resources services do not come neatly packaged
available in Liverpool to create a far-reaching and,certainly in the domains of health and
and visionary plan to improve the health and social care, present increasingly with complex
well-being of its people. This combined with and multiple problems. The vision for Liverpool
Report of the Mayoral Commission 5
should acknowledge this dimension and in the agencies around the needs of individuals and Change needs to happen in the context 3: It is recommended that the system be
same way that service provision and delivery will their communities. The Commission saw great of the city region and surrounding North stimulated by a major new initiative to
need increasingly to be innovative, the people opportunities for meaningful integration around West of England, where there are close integrate out of hours services across
delivering it will require broad and flexible skills. a neighbourhood model of care provision that interdependencies of the constituent parts. primary, community, secondary,
brought together all relevant health, social care, Similar challenges are facing all cities in the tertiary, mental health and social care,
In the past, a significant barrier to true and other resources within a defined area, but UK, but Liverpool is well placed to exert some of commissioned by Liverpool Clinical
integration of care has been the failure to recognised that this would at the same time the levers identified here and should seize the Commissioning Group, NHS England
integrate information systems, to use new raise issues about funding, accountability, opportunity to become an exemplar for others (Merseyside), and Liverpool City Council,
technologies appropriately, and to share data leadership and sustainability. to follow. and so become a national exemplar.
across agencies. Success of many of the
Commission’s recommendations will rest heavily Developing and putting in place a It is clear that the Commission’s vision for The further seven recommendations makeup
on overcoming these barriers. comprehensive system of health and well-being Liverpool will need strong and easily identifiable the Commission’s 10 Point Integrated Health
for Liverpool will require not only the cooperation leadership, backed up by political will. Authority and Social Care System recommended to the
In order to free up resources for modern and collaboration of partners but also a will be required to resolve the competing Mayor include Coproducing the Integrated
healthcare, there must be a combination large measure of political will to see through priorities that will inevitably result from the Plan; Developing the Neighbourhood Model;
of: reducing requirements through improved the necessary changes. It will also require a prospect of radical change. It is likely also Creating the NHS Workforce for the future;
population health; increasing individual realistic time scale for implementation and that this authority will need to extend beyond Leadership based on Research and shared
responsibility for health and self-management; resolution, what is envisaged is not the relatively Liverpool if negotiations are required with Information and; the wider role of the city.
shifting more care out of hospitals into the simple task of identifying ‘problems’ and listing national bodies, including with government.
community where it can be most cost-effective; ‘priorities’. What the leaders of this enterprise will Achieving the vision set out in these
and reducing wasteful duplication of services or be required to do is effect a major change in The written submissions received by the recommendations will require strong operational
unnecessary competition. behaviour both in partners and in the people of Commission in response to its seven questions over-sight and support from a number of
Liverpool. contain a wealth of detailed, sound, practical individuals, organisations, and other sources.
Greater integration of care across the whole and thoughtful suggestions and actions, and The urgency of action cannot be emphasised
system is the only feasible way to achieve these While many of the Commission’s provide an excellent platform to go forward. The strongly enough and it is essential that there
recommendations will take years to implement Commission commends them. is oversight and scrutiny of the ten-point
aims. Any plan will need to strike a balance
between where the boundaries of agencies lie; fully, there is an urgency to start and to seek implementation plan.
The report recommendations are a starting
boundaries defined not only in geographical short-term as well as long-term gains. In this
point for change. The first three are over-arching
terms but also by what is in the best interests respect there are several reasons why the
and strategic, and set the vision in broad terms:
of people and patients. This is likely to result Commission’s report is timely:
in some unusual and innovative pairings
1: It is recommended that all the key
and partnerships, of which we have already • The central university hospital, the Royal
partners in Liverpool (including the City
seen many signs in the city. For example, the Liverpool, is about to be rebuilt as a state
Council, Liverpool Clinical Commissioning
fire service joining with social care; business of the art hospital and will create the
Group, NHS England (Merseyside), NHS
collaborating with public health; doctors and environment for a new Bio-campus;
Trusts, Liverpool Health Partners, the
nurses working with musicians, artists, and • The hospitals in the city are already working
Academic Health Science Network,
footballers. Community pharmacies have the with the University of Liverpool in a body
and the voluntary sector) formally sign
potential to be invaluable partners too. called Liverpool Health Partners, which is
up to the principle of seeking to create
committed to jointly fostering the highest
a pioneering, high quality, sustainable
There is unanimous commitment across the standards of clinical service, education and
Integrated Health and Social Care
health and social care landscape in Liverpool biomedical research in the city;
System for Liverpool, and undertake
to embrace more integrated care but there • The award from the Department of Health
together to lead, manage, and fund the
are significant barriers to this in practice, of the North West Coast Academic Health
transformation of the health outcomes of
such as perverse funding incentives, and Science Network and the Collaboration for the people of Liverpool.
over-prescriptive national scrutiny of financial Leadership in Applied Health Research and
targets rather than population needs. Tackling Care with a focus on applying research 2: It is recommended that prevention and
these will require imaginative commissioning findings to spread innovation and to tackle self-care become the primary focus
of both secondary and tertiary services by health inequalities; in the transformation of the health
commissioners, and strong leadership to • The proposed development of the Liverpool outcomes of the people of Liverpool, and
influence national agendas. Biomedical Research Centre in Personalised within this a focus on young people and
Health within Liverpool Health Partners; and the elderly should be priorities. This will
Liverpool’s primary care structure is already • The Commission is reporting to an elected require tackling the social determinants
well-developed around 18 neighbourhoods mayor, the first of any UK core city, with local of health and directly engaging the
these have the potential to bring together other and national influence. citizens of the city.
6 Report of the Mayoral Commission Report of the Mayoral Commission 7
Recommendations Achieving the vision set out in these
recommendations will require strong operational
• A commitment to the pace and scale
required to initiate this transformation as well
• Linking with schools, adult, and further
education, and Sure Start Centres to align
over-sight and support from a number of as to the need for continuing change over with the neighbourhood model approach;
The Commission heard abundant evidence individuals, organisations, and other sources. a decade; and
from a wide variety of organisations in Liverpool Therefore the Commission further recommends • Using intelligent and proactive • Developing and aligning the current
about the resources, skills, vision, and, above all, the following: commissioning to prioritise collaboration range of community health staff (for
the willingness of those organisations to engage over competition and to overcome example health trainers, community health
in a single, unified plan to transform the health Co-producing an Integrated Plan fragmentation, gaps, and silo mentality in ambassadors, health promotion and social
of the people of Liverpool. health providers; inclusion teams etc) into a more coherent
4: It is recommended that a single unifying • Exploring ways of working with the whole and larger cohort of Community Health
Such is the extent of the poor health outcomes strategic plan is developed, based on the system to invest more in budgets for workers, based in neighbourhoods and
of the people of Liverpool, and the relentless City’s Joint Strategic Needs Assessment prevention and to free up resources for interfacing between clinical staff and the
drive on budgets and resources, that only a bringing together the local commissioning improving community well-being and community.
wholesale comprehensive approach to their plans of the Clinical Commissioning Group, resilience;
transformation is likely to succeed. the City Council, the Health and Well-being • Developing pooled budget initiatives and Creating the NHS Workforce
Strategy of the joint Health and Well-being exploring alternative funding models around for the future
The Commission’s vision is an Integrated Board, and NHS England (Merseyside). capitation;
Health and Social Care System for Liverpool, • Targeting early years and pregnancy as 8: It is recommended that the workforce
with prevention and self-care at its core. To 5: It is recommended that national bodies such investment for the future so that children strategy needed to deliver a high quality,
achieve this there is a 10-point plan. The first as NHS England, Health Education England, receive the best start in life; and integrated 24/7 service, and to transform the
three are over-arching recommendations that Monitor, the Care Quality Commission, • Implementing a family service approach, health outcomes of the people of Liverpool
set the vision: the NHS Trust Development Agency, Public for example using antenatal care as includes the development of new roles,
Health England, and Health Watch be kept an opportunity to assess and influence where needed assisting existing staff to work
1: It is recommended that all the key partners fully informed of the strategic plan, to allow maternal, child and family health. differently, giving young people access to
in Liverpool (including the City Council, space for the reduction of duplication and new opportunities and supports wherever
Liverpool Clinical Commissioning Group, unnecessary competition (particularly in Developing the possible the recommendations of the Mayor
NHS England (Merseyside), NHS Trusts, secondary care), and for the restructuring of Neighbourhood Model of Liverpool’s Education Commission.
Liverpool Health Partners, the Academic primary, community, secondary, and tertiary
Health Science Network, and the voluntary services to improve the patient pathway and
7: It is recommended that a Neighbourhood This will include:
sector) formally sign up to the principle of quality of care. Support from these bodies is
Model be the key way of implementing the
seeking to create a pioneering, high quality, critical for the realisation of the strategic plan.
proposed Integrated Liverpool Health and • Developing new well-trained generic care
sustainable Integrated Health and Social
Social Care System. practitioners across health and social care,
Care System for Liverpool, and undertake 6: It is recommended that locally Liverpool
and, working with local Higher Education
together to lead, manage, and fund the Health Partners and the North West Coast
transformation of the health outcomes of the This will include: Institutions, Health Education England (Local
Academic Health Science Network play a
people of Liverpool. Workforce Education Group), and providers
key part, through research-based input from
• Building on Liverpool’s current primary care of health and social care to develop new
the academic community and their links
2: It is recommended that prevention and Neighbourhood Health Centre structure and qualifications to bridge NHS and Social
to industry, in helping primary, community,
self-care become the primary focus in the network; Services;
secondary, and tertiary providers to ‘act as
transformation of the health outcomes of the • Ensuring that primary care, community • Working with Health Education England,
one’ and to work together across traditional
people of Liverpool, and within this a focus health, mental health, secondary care, Liverpool City Council, the Local Enterprise
boundaries.
on young people and older people should and public health interventions and Partnership, and the Academic Health
be priorities. This will require tackling the resources are aligned wherever possible at Science Network to develop enhanced
Co-producing this integrated plan with wide-
social determinants of health and directly neighbourhood level; NHS initiatives for apprenticeships, local
ranging partnerships will require:
engaging the citizens of the city. • Building into neighbourhoods close links with employment, and back to work schemes
• Building a coherent joint leadership and the social care and voluntary sectors, and that target people from disadvantaged
3: It is recommended that the system be management structure founded on an local community assets; communities;
stimulated by a major new initiative to ethos of collaboration; • Bringing multiple services to common • Developing and expanding NHS cadetships
integrate out of hours services across • Developing integrated provision for health neighbourhood sites, for example and schemes for young people to
primary, community, secondary, and care in the community; housing, benefits, Citizens’ Advice, debt experience health services particularly in the
tertiary, mental health and social care, • Implementing a strong sustained management, etc; community, and working with the Healthy
commissioned by Liverpool Clinical • Working towards true co-terminosity between Schools’ team and the Schools’ Parliament
communication and marketing plan
Commissioning Group, NHS England agencies, for example between the police, to grow a ‘Health Champion’ role in every
to enable the people of Liverpool to
(Merseyside), and Liverpool City Council, the fire service, social care, and community secondary school in the city;
understand the scale of the challenge and
and so become a national exemplar. health;
the role they can play;
8 Report of the Mayoral Commission Report of the Mayoral Commission 9
• Encouraging the Liverpool Learning The wider role of the City • Urging all NHS organisations, along with ensure healthy and sustainable places and
Partnership to add ‘health’ as a crucial other major employers, to seek to pay communities across the whole city;
component of the Liverpool Local 10: It is recommended that the City of Liverpool the Living Wage as recommended by the • Promoting the development of Liverpool-
Curriculum, proposed by the Mayor of and all its organisations commit to the Liverpool Fairness Commission. Active City as an international exemplar
Liverpool’s Education Commission, bringing transformation of the health outcomes of for mass participation in physical activity,
health and social care role models into the people of Liverpool by tackling the wider Engaging the Community especially for young people and the elderly;
schools. determinants of health and facilitating the • Liverpool becoming an exemplar city for
healthy choices in food, alcohol, smoking, • Working with the voluntary sector to the reduction of alcohol-related harm
Leadership based on research and exercise, and transport. mobilise community action to bring about by building on partnerships that have
shared information sustainable large scale change, including developed in this field between the local
This will include: innovative participatory funding for local authority, police, the NHS and employers;
9: It is recommended that the transformation action, and enhancing partnerships to and
of the health outcomes of the people of Health is Wealth maximise the effect of the Liverpool pound; • Supporting the commitment of the City
Liverpool through the Integrated Health • Building on community engagement Council to work across the Liverpool city
and Social Care System is research and • Recognising that ‘Health is Wealth’ and that through projects such as: the football region to implement the 50 pence minimum
evidence-based. a healthy city will attract funds, business, clubs’ community programmes; arts unit price for alcohol, as well as using its
and visitors for the benefit of the city, its projects (for example the Royal Liverpool licensing powers to curb off licences and
It is further recommended that priority be businesses, and its people; Philharmonic Orchestra’s ‘in harmony’); fast food outlets near schools.
given to improved data sharing across the • Celebrating Liverpool’s unique capabilities, green environmental projects (for example
whole of health and social care and to an Natural Choices and Live-ability for the
The Way Forward
a range of high quality institutions, strong
integrated electronic record, to the benefit of partnerships, a tradition of health leadership elderly population); and
direct patient care, innovation and research. and innovation, and strong specialist • Working with the Mayoral Lead Voluntary
services to achieve the transformation and Community Sector Champion and All of the Commissions’ 10 recommendations
This will include: required; key local voluntary sector organisations will require continuing work, monitoring,
• Inspiring the people of Liverpool to engage to increase volunteering in the NHS and evaluation. Some will require Task and
• Encouraging the close collaboration wholeheartedly in the transformation, and by developing a new accredited role, Finish Groups, for example in delivering the
between Liverpool Health Partners, the creating an inclusive, stream-lined and recognised by the Mayor, of ‘Health recommendation to create the NHS workforce
Academic Health Science Network, the equitable Integrated Health and Social Champion’ building on initiatives such as for the future; others such as developing the
Comprehensive Local Research Network, Care System that is understandable and the Mi/Dallas champions, the Black and Neighbourhood Model will benefit from a high
and the North West Coast Collaboration for accessible to the whole population; and Minority Ethnic Champion network, and profile city-wide conference involving all the
Leadership in Applied Health Research and • Each organisation validating its activities to the Football Clubs’ Champions. For some parties. It is vital that this further work on all
Care to support evidence-based research ensure it makes the healthy choice, the easy participants this might be a first step into recommendations is undertaken urgently.
and evaluation of the Commission’s choice. employment as well as a voluntary role.
proposals; to oversee translation of research The Commission acknowledges the valuable role
into innovation and action; and to speed Corporate citizenship and Enhancing health promotion; the Mayor of Liverpool has played in convening
up the implementation of proven successful sustainability preventing ill health a regular Health Summit attended by all the key
change for the benefit of patients; local health and social care organisations, and
• Working with the Academic Health Science • Ensuring all local employers, including NHS • Continuing to invest in prevention initiatives this has been an important step in encouraging
Network, the national Technology Strategy trusts, adopt the Workplace Well-being around smoking, diet, exercise, drugs, partnership working. It is vital that there is clear
Board, the Local Enterprise Partnership, Charter, developed in Liverpool and now alcohol, and sexual health, and combining leadership in the way forward.
Liverpool Vision, and the Mi(Dallas) initiative, the national NHS standard, and build these in a more ‘joined-up’ ‘wellness service’,
to promote the City Region as a Centre compliance with this standard into supply- to prolong a healthy life as well as prevent The Commission believes that the future of the
of Excellence for Assisted Living New chain contracts; premature death; city depends on its people, and the Mayor
Technology; and • Encouraging the NHS and all local • Continuing the 2020 Decade of Health and City Council are well placed to continue to
• Working with the Local Enterprise Partnership, organisations to prioritise local procurement and Well-being’s innovative Public Mental monitor the progress of the various health and
Liverpool Vision, Liverpool Health Partners, in the City, making use of the Public Service Health promotion of the New Economic social care organisations in the coming months
and the Academic Health Science Network (Social Value) Act 2012 with its commitment Foundation’s 5-ways to Well-being – and years. It believes that implementation
to position Liverpool as an international to the improvement of social, economic, Connect, Keep Learning, Be Active, Take of these recommendations is urgent and
centre for the life-sciences, including and environmental well-being; Notice, Give (CLANG); encourages the Mayor to:
personalised medicine, pharmaceutical • Supporting the NHS to develop more • Targeting for extra support the most • Invite all key partners to sign up to the
trials, and the exploitation of ‘big data’. sustainable transport, energy and natural vulnerable groups and those most at recommendations the report
environment policies, such as the local NHS risk through social, economic, or racial • Use it as a springboard for establishing a
Carbon Collective and further improvements disadvantage, and acting with partners formal review mechanism for ensuring that
in cycling facilities; and on the wider determinants of health to action is taken.
10 Report of the Mayoral Commission Report of the Mayoral Commission 11
1.3
1.Overview of Liverpool The Index of Multiple Deprivation 20102 identifies
Liverpool as the most deprived local authority
1.1 in England, with the most severe deprivation
During the coming months and years, concentrated in the north of the City (see
the people of Liverpool face considerable map 1): the extent of deprivation is by far the
challenges to their health and well-being. greatest issue facing health in the City. While
Some of these are rooted in what are termed inequalities in life expectancy between Liverpool
the ‘social determinants of health’; others are and England are decreasing, there remains a
looming, for example, financial pressures linked significant gap. Within Liverpool, males in the
to a number of factors, increased demand more deprived areas of the City die over 10
competing with decreased resources. The years sooner than their counterparts in the most
need for a solution is critical. This report sets affluent areas; for females the variation is just
out Liverpool’s challenges in some depth and over 7 years (see figure 2).
proposes a way forward.
Map 1 Levels of Deprivation in Liverpool
1.2
Liverpool is home to 466,415 people living in
206,515 households1 making it the fifth largest
of the eight core cities. 86.2% of the population
describes itself as ‘white British and Irish’ a rate
which is higher than the national rate of 81.4%.
© crown copyright and database rights 2011. Ordinance survey 10001835
There is, however, a long-standing Liverpool-
born black community, as well as long-standing
Chinese and Somali communities (see table
1). Liverpool’s population is a relatively young
one with a significantly higher proportion than
the national average aged 15 to 35 years. The
average age in Liverpool in 20111 was 35.4 years
compared with 38 years in England. However,
as in many other parts of the country, the
resident population is an aging one with an
increasing proportion aged 80-plus years, a
section of the population which is forecast to
increase by over one third during the next 20
years, bringing the total in this age group to
85,000 (see figure 1). Equal to or less than 1% (most deprived)
Greater 1% and equal or less than 5%
Table 1: Liverpool Population Greater 5% and equal or less than 10%
Greater 10% and equal or less than 20%
by Ethnic Group
Greater 20% and equal or less than 50%
Ethnic Group Liverpool England
Greater 50% and equal or less than 100%
White 88.9 % 86 %
• British 84.8 % 80.5 % IMD 2012
• Irish 1.4 % 0.9 %
• Other 2.6 % 4.4 %
Mixed/multiple ethnic 2.5 % 2.3 % 1.4
groups One in three Liverpool children live in poverty
Asian/Asian British 4.2 % 7.8 % compared with one in five children in England.
Black/African/ 2.6 % 3.5 % Figures show that there were around 32,200
Caribbean/Black British (15%) lone parent households at the time
of the 2011 Census1, with 21,200 containing
Other ethnic group 1.8 % 1.0 %
dependent children. This compares to
ONS Census 2011 10.7% nationally1. Almost one in three of the
Report of the Mayoral Commission 13
Figure
25%
1:Projected population change in Liverpool between 2012 - 2021 population experiences poor mental health, alcohol-related treatment, the equivalent
25%
compared to around one in six across the North of 64,750 visits per year. However, only 6% of
20%
West. Mental illness is associated with reduced emergency departments in the UK offer alcohol
20%
15%
life expectancy of between 15 to 20 years3 harm-reduction interventions to patients aged
15%
10% . 16 years or under. The Centre for Social Justice
10%
5% put Liverpool sixth amongst local authorities in
15-19 20-24 25-29 30-34 40-44 45-49 50-54 75-79
5%
0% 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
1.5 England for alcohol-attributable admissions to
0%
-5% 0-4 5-9 10-14 35-39 55-59 60-64 65-69 70-74 80-84 85+ The negative impact of alcohol amounts to a hospital in 2010-11, with 31.53 per 1,000 adult
-5%
-10%
burden of expenditure on the City of more than males admitted5.
-10%
£228 million per year, representing an average
-15%
spend of £512 for every man, woman and child. 1.8
-15%
-20%
For those under 18 years of age in Liverpool, The incidence of cancers is significantly higher
-20%
-25% cannabis and alcohol remain the key “problem than the national rate and has increased at
-25% substances” and evidence from the National twice the national rate over the last decade.
ONS Interim 2011 subnational population projections for England and 2012 MYE’s Treatment Agency for Substance Abuse4 Approximately 2,500 Liverpool residents are
suggests that those who use these are doing so diagnosed with cancer each year, 438 more
Figure 2: Trends in Life Expectancy more intensively than ever. Specialist services than would be the case if the local incidence
100 100 are effective for those that engage with them rate equalled the national average. The
100 100
and help to prevent them from becoming the incidence rate for lung cancer in Liverpool
problem drug and alcohol users of the future. remains at twice the national average.
A report from The Centre for Social Justice5
gland put Liverpool fifth in a list of local authorities in 1.9
Women in En
80 England 80 g land England for opiate and/or crack use in 2010-11, Levels of worklessness in the City are well above
Men in Women in En
80 England 80 en in Liverpool
with 17.42 per 1,000 adults affected. the national average, with 22% of working age
Men in Wom
AGEAGE
adults claiming out of work benefit compared
AGEAGE
po ol
ol Women in Liver
Men in Liverpo 1.6 to 12.5% for Great Britain1. Liverpool has the
Liv er po ol
Men in Alcohol related harms are increasing in Liverpool second lowest average household income
despite overall population levels of consumption of the eight core cities. 28% of Liverpool’s
60 60 reducing nationally. Nationally, girls aged 15-16 population are believed to live in a Housing
1995-97
1996-98
1997-99
1998-00
1999-01
2000-02
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
2008-10
2009-11
2010-12
1995-97
1996-98
1997-99
1998-00
1999-01
2000-02
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
2008-10
2009-11
2010-12
60 60 years report binge drinking and drunkenness Association property1.
1995-97
1996-98
1997-99
1998-00
1999-01
2000-02
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
2008-10
2009-11
2010-12
1995-97
1996-98
1997-99
1998-00
1999-01
2000-02
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
2008-10
2009-11
2010-12
more than boys. Binge drinking is also a key
ONSEngland
2011 England
factor in teenage pregnancy, another major 1.10
England England problem for Liverpool and girls are also more Of the 14,000 people using adult social care
Bristol Bristol
Figure 3: Trends in Admission Episodes for Alcohol-related Conditions likely than boys to be admitted to hospital for services during the course of a year, 68% are
Bristol
Sheffield Bristol
Sheffield alcohol related harm. Evidence suggests a over the age of 65 years. The most common
Directly
SheffieldStandardised Rates per 100,000 population , all ages
Sheffield
Leeds Leeds strong association between heavy episodic primary need group is physical disability,
3500
Leeds Leeds binge drinking and violent youth offending. followed by mental health, inclusive of
Birmingham Birmingham
Birmingham
North West Birmingham
North West
Underage heavy episodic binge-drinking, dementia. Forecasted trends indicate that by
3000 defined as consuming five or more drinks on 2030 demand for social care will have increased
DSR per 100,000 population
North West North West
MEN WOMEN
Nottingham Nottingham
one occasion, is associated with a range of by more than a fifth, a potential increase of
MEN WOMEN
Nottingham
Newcastle Nottingham
Newcastle negative health and social outcomes including 3,000 service users8.
2500
Newcastle Newcastle
LIVERPOOL
ol
LIVERPOOL accidents, physical and mental health
rpo
LIVERPOOL Live st LIVERPOOL problems, poor school performance, anti- 1.11
Manchester h We Manchester
2000 0 Nor t social behaviour and violence. The National But along with this there have been
Manchester Manchester 0
10 20 30 40 50 60 70 80 and20 40 60 80 100
E ngl Offending, Crime and Justice Survey found that improvements. Since 2001 Liverpool has seen
0 10 20 30 40 50 60 70 80 0 20 40 60 80 100
underage drinkers who drank at least once a the second largest reduction in premature
1500
week commit a disproportionate number of mortality among the eight core cities in
offences, particularly violent offences6. England, falling by almost a quarter from 496.6
1000 per 100,000 to 374.9 per 100,000 between
1.7 2001 and 2011. There have also been marked
500 A report by the UK Department for Children, improvements in lifestyle. In particular the
Schools and Families7 estimated that prevalence of smoking fell from 35% among
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
2008-10
2009-11
2010-12
approximately 1,245 young people attend adults aged 16+ in 2005 to 26% in 2011, and
LAPE hospital emergency departments weekly for there is some evidence of a levelling off in
14 Report of the Mayoral Commission Report of the Mayoral Commission 15
alcohol related hospital admissions8 1.15
Figure 4: Main Causes of Death in Liverpool (See figure 3). The combined impact of NHS resources frozen in
Stomach
cancer
An overview of the main causes of death in real terms and continued increases in demand is
Accidental
Poisoning Transport
41 Stomach and Liverpool can be seen in figure 4. demonstrated in Figure 5, compiled by the widely
accidents
digestive organs
Senility without mention of psychosis Blood disease and
Exposure to smoke,
fire and flames
39
10
Colon cancer
respected Nuffield Trust. This identified a potential
immune system2. The Mayoral Each area is discussed in Chapter 3. A
summary of recommendations and the way
Commission on Health forward follow in Chapter 5.
2.1 2.4
The Mayoral Commission on Health (the Throughout its work, the Commission was
Commission) took place in the middle of some struck by a readiness on the part of all those
of the biggest changes in the organisation providing evidence to commit themselves and
of the NHS since its inception in 1948. These their organisations to improving the health and
include: the setting up of new Health and well-being of the people of Liverpool. There
Well-being Boards; Clinical Commissioning was universal willingness expressed amongst
Groups with their new ways of commissioning witnesses to work in partnership with each other
health services; and in line with national policy to achieve this, and recognition that improved
the transfer of responsibility for the City’s public outcomes for patients are more important
health from the NHS to the local authority. At the than organisational needs. The Commission
start of formal Commission evidence gathering, applauds this, but recognises that willingness
the Primary Healthcare Trust (PCT) ceased to and commitment alone are not enough.
exist and was replaced by the Liverpool Clinical Change on the scale set out in this report will
Commissioning Group (CCG), as well as by require strong leadership and those taking
the other organisations which collectively have responsibility will need to act with some urgency.
taken on the PCT functions.
2.2
This, together with some of the worst health
and deprivation statistics in the country, is the
context within which the Commission undertook
its work. Liverpool is a city with a much higher
than national average prevalence for factors
known to have a negative impact on health
and well-being, set in a landscape of national
change and local transition. The organisations
which serve the City, and on which it can
draw to realise the vision set out in this report,
comprise its ‘asset-base’ and resources. These
are described according to their relevance to
the work of the Commission in Chapter 3.
2.3
In considering the material put before it, the
Commission has identified nine areas for
further comment, where the direction of travel
to improve the health and well-being of the
people of Liverpool should be focussed. These
are:
• The people of Liverpool
• Prevention and health promotion
• Integrated care
• Incentives
• Organisations to deliver the plan
• Workforce and skills
• A healthy economy
• Evidence and research
• Technology and health.
Report of the Mayoral Commission 193. The City of Liverpool’s 3.2
The following paragraphs describe briefly
Assets and Resources the current Liverpool landscape in terms of
the organisations that provide its healthcare
3.1 (in the City and wider); the services and
Liverpool as a city has experienced enormous networks linked to these; and bodies not linked
ups and downs in its history. Growing its wealth organisationally but which make a major
from the slave trade it developed a Georgian contribution to their wider work. They constitute
architecture unrivalled outside London and the assets and resources that Liverpool will be
aspired to be the ‘Athens of the North’. It able to draw on to realise the vision set out in
became the ‘second city of Empire’ with the this report. Some are new and emerging; others
confidence to build St George’s Hall, the largest are well established. Together they represent
neo-classical building in Europe, and the Three significant capital, human and material, with
Graces on the Waterfront. Huge wealth co- enormous experience and expertise to improve
existed with enormous poverty, deprivation, and patient services and outcomes. With their
ill-health, all of which inspired the appointment courage, resilience, tenacity and humour, the
of the first director of public health in the people of Liverpool are arguably its greatest
country, the visionary Dr Duncan. The City still asset. Their pivotal role in improving the City’s
shows some scars of its key role in World War II. health is discussed in Chapter 4.
A huge port-based work force was gradually
diminished with a new manufacturing base
emerging, which itself declined by the 1980s. By
the turn of the millennium, after a difficult period
marked by inner city riots and a controversial
city council, Liverpool started on the road to
renewal, with the European Capital of Culture
year of 2008, a symbolic turning point in the
City’s new history which has also seen a new
Conference Centre and Arena on Liverpool’s
stunning waterfront, a major new shopping
centre Liverpool ONE, and a totally refurbished
Central Library.
Map 2: Local Clinical
Commissioning Groups
© crown copyright and database rights 2011. Ordinance survey 10001835
Report of the Mayoral Commission 21Healthcare Clinical Commissioning to develop ‘joint strategic needs assessments’ Partnerships and networks
as the basis of a joint health and well-being
3.3 3.5 strategy. In Liverpool this work is well underway 3.10
In Merseyside there are six Clinical In April 2013, Liverpool NHS PCT ceased to and involves many of the partner organisations Over the recent months some notable
Commissioning Groups (map 2); four acute exist and, in line with national policy, was from which the Commission took evidence. partnerships and networks have been
trusts; three specialist trusts; two community replaced by NHS Liverpool CCG and the other established, or are being planned, to further
trusts; one mental health trust; one children’s new organisations mentioned below. The NHS England (Merseyside) support Liverpool’s health and well-being and
trust; and 1,050 general practitioners in 248 contribution made by the PCT to improving the social care systems. Liverpool Health Partners
general practices. Thus the people in the City health and well-being of the people of Liverpool 3.8 (LHP) is a strategic partnership creating an
region have access to a wide range of high is set out in its public health directorate Health Formerly established as the Local Area Team Academic Health Science System for the City
quality clinical services, ranging from the ‘every Improvement 2002-2013 document10 which of the NHS Commissioning Board in October Region and beyond, delivering excellence
day’ care provided from general practice to describes the PCT’s considerable achievements 2012, NHS England is an independent body, in research, healthcare delivery and clinical
care from facilities with a world-wide reputation in reducing health inequalities in Liverpool. This at arm’s length from the government. Its main education, and ultimately translating bio-
for excellence. There has been considerable is a remarkable legacy on which the City can role is to improve health outcomes for people medical research to direct clinical benefits for
recent investment in physical assets with new now build. in England. In this respect, the interests of the patients.
development planned around Aintree, Alder people of Liverpool are incorporated into the
Hey, the Royal Liverpool hospitals and Mersey 3.6 work of NHS England (Merseyside), which has 3.11
Care NHS Trust. With the proposed Bio-campus The NHS White Paper11 handed over wider responsibility than for Liverpool alone, The Northwest Coast Academic Health Science
there is potential for the Liverpool City Region to commissioning responsibility on 1 April 2013 to but which includes Liverpool CCG and a Network (AHSN), which covers Liverpool, is
be a world-class centre of excellence in the life general practitioners through local CCGs and to number of acute, specialist, and community one of 15 such NHS bodies being established
sciences and healthcare. NHS England. Thus, the newly created Liverpool NHS trusts all serving the health needs of the nationally. Their function is to spread innovation
CCG has assumed responsibility for improving people of Liverpool. Work to address these at ‘scale and pace’ which means the
Public health health outcomes for the people of Liverpool, needs has started in earnest and NHS England implementation of new treatments or health
around half a million of them, registered with (Merseyside) is working with patient, professional technologies, or the application of existing
3.4 95 general practices, grouped in turn into 18 and other partners to shape a vision for primary treatments and technologies in new ways.
Following the Health and Social Care Act 20129, neighbourhoods. The 95 General Practices care.
Liverpool’s public health function now resides in the City are all commissioned to deliver the 3.12
with the local authority, the body that is also Liverpool General Practice Specification, which The voluntary sector and The Northwest Coast Collaboration for
responsible for the provision of social care sets out standards of care over and above independent charities Leadership in Applied Health Research and
services. Public Health in Liverpool has provided those required in the national contract. Building Care (CLAHRC) has been established recently
a strategic direction for health and well- on the work of the PCT, the CCG has adopted 3.9 with a £9.5 million grant from the Department of
being for several years and, in spite of revised an approach designed ‘to secure a sustainable The voluntary sector in Liverpool is a vibrant one Health. Although extending beyond Liverpool
working arrangements and re-organisation, model of care which promotes health and offers with more than 2,000 grassroots organisations the work of the CLAHRC is focussed on health
this remains unchanged and as committed as value and service quality’ and has embarked as well as charitable organisations operating inequalities, which is particularly relevant for the
ever before. The strength of Liverpool’s public on a programme of work to achieve the aims on a regional or national basis. The umbrella city. The CLAHRC will deliver innovative applied
health function is added to by the academic of its approach by 2020 aspiring that ‘[by 2020] body for the non-profit sector in Liverpool is health research to improve the quality of care,
public health departments at Liverpool and health outcomes for people within Liverpool will Liverpool Charity and Voluntary Services but focussing on chronic disease and public health,
Liverpool John Moores Universities. Public Health have improved relative to the rest of England informal links exist between several of the linked to implementation. It is hosted by the
in Liverpool is playing a key part in the work of and health inequalities will be narrowed’. voluntary organisations and statutory bodies Liverpool CCG and interfaces directly with the
the CCGs, Health and Well-being Boards, and Support for the CCG in its commissioning role with arrangements in place between them AHSN and LHP.
the development of the joint strategic needs has been available from the Merseyside and for the provision of patient and carer support
assessments referred to in paragraph 3.7. Cheshire Commissioning Support Unit, a body services. Some, for example Health at Work, are 3.13
that emerged from the NHS reforms and which specifically focussed on health and well-being; The Comprehensive Local Research Network
is currently hosted by NHS England. others operate on a small scale and reach out has a mandate to deliver Department of Health
to individuals and communities with practical National Institute of Clinical Research approved
3.7 and personalised solutions to a range of issues research into 25 NHS trusts within the Cheshire
In addition to these changes, public health that impact negatively on health and well- and Merseyside area. In the coming year the
responsibility and leadership was moved to being. area will enlarge to bring in South Cumbria
local government. Health and Well-being and Lancashire and will be hosted by the Royal
Boards, based in local authorities, are the Liverpool Hospital. The network has a strong
means of bringing together NHS commissioners record in recruitment to and delivery of major
and others with the purpose of coordinating the trials that shape healthcare and outcomes.
local public health agenda. Under the 2012 The role of the network is expected to evolve
Act9 Local Authorities and CCGs are required with a greater emphasis on patient and public
22 Report of the Mayoral Commission Report of the Mayoral Commission 23engagement in research, liaison with health Education and training
commissioners, and closer working to build
research capacity within the geographical 3.15
footprint. The quality of staff charged with delivering
health and well-being and social care to
3.14 the people of Liverpool will be critical to the
The Liverpool and Sefton Health Partnership, success of any health improvement plan.
the Local Improvement Finance Trust (LIFT) for Developing the strategy needed to deliver the
Liverpool and Sefton, was formed in 2004. LIFT is workforce to support the NHS in the future and
a government initiative designed to assist in the to commission the education and training of
delivery of improved primary and community staff locally is the responsibility of the Cheshire
health infrastructure. In Liverpool this has been and Merseyside Local Workforce and Education
particularly successful and Liverpool is regarded Group (LWEG) which is part of Health Education
as one of the major success stories nationally. Northwest (the largest Local Education and
There are now 18 neighbourhood health Training Board (LETB) in the country). The remit
centres across Liverpool, 12 of them new builds, of LWEG includes doctors in training, student
delivering a range of services close to people’s nurses, midwives, allied health professionals,
homes, with capacity to extend its influence healthcare scientists and unregistered workforce
in terms of the facilities and the innovative including apprenticeships. The Cheshire and
solutions they can accommodate. Merseyside LWEG is made up of representatives
at board level of all the providers of healthcare
as well as local universities, primary care and
public health.
3.16
Although not all the health and social care
workforce will be ‘home grown’, Liverpool City
Region’s universities provide first class education
and training opportunities in health and social
care that put the City in an excellent position to
populate its health and social care system with
locally educated talent.
Report of the Mayoral Commission 254. Findings the patient rather than managed round the
budgets of each participating organisation.
A common agenda
4.6
It was abundantly clear that health and well-
4.1
being are dependent on a wide range of
There was clear recognition by all witnesses
factors outside the direct remit of the NHS
of the urgent need to address and transform
including housing, debt, education, social care,
the health of the people of Liverpool. Some
lifestyle options, the environment, proliferation of
witnesses emphasised that not taking major
fast food outlets, bicycle tracks, city infrastructure
action to improve health would, inescapably,
etc. Further information about the social
guarantee ever-increasing demands on health
determinants of health can be found in
services that simply could not be met within a
Professor Sir Michael Marmot’s report on health
context of declining resources and increasing
inequalities in England 12.
costs.
4.7
4.2
Transforming the health of the people of
This recognition was matched by an equally
Liverpool necessitates the broadest possible
strong willingness among all witnesses
approach that includes the whole range
to commit their organisations to work in
of relevant agencies and services whose
partnership for the common cause and
contribution to the well-being of the citizen may
a shared vision to transform the health of
at times outweigh any direct contribution from a
the people of Liverpool, even though they
healthcare provider. This could involve making
understood this might mean gains and losses
housing and employment advice, and debt
for each of them. Despite those consequences
counselling available at sites where primary
they were willing to unite on a common agenda
healthcare services are also delivered. It could
including playing their part in defining the vision
involve a City-wide approach to countering the
and subsequently implementing it.
harm caused by smoking, obesity and alcohol
misuse, delivering public health messages in a
4.3
consistent, coordinated and imaginative way
Witnesses saw clearly the part the health
to every individual. It was clear that solutions
community in Liverpool could play in creating
may at times be more non-clinical than
not only a healthier population, but also adding
clinical. The Commission heard of many local
value to the overall health and wealth of the
innovative examples to tackle the underlying
Liverpool economy.
determinants of ill health such as the Healthy
Homes programme, the Liveability Active Aging
What the vision needs to be
project and the Natural Choices environmental
programme, as well as many city-wide health
4.4
campaigns.
The challenge of transforming the health of
the people of Liverpool is enormous. Witnesses
4.8
repeatedly noted that the vision and actions
Across the whole of Liverpool and in all
would need to be radical, broad-reaching
circumstances, the ‘healthy choice has to
and comprehensive. Tinkering with parts of
become the easiest choice’.
the system will not achieve the magnitude of
change required.
4.9
This, in turn, necessitates an unprecedented
4.5
degree of integration, common agenda,
The vision must put people and patients at
shared vision and shared planning between
its heart and be informed by and respond to
the wealth of agencies involved in all aspects
their expressed needs. The focus of the vision
of a person’s life. Services must be designed
needs to be on service user benefit rather
around the needs of patients rather than
than on service reconfiguration for the sake of
around existing systems. Today there are a
it. Resources need to be managed around
large number of independent organisations
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