The plates may be moving, are we ready?

Over the weekend we have seen the results of the local elections create a fairly consistent picture of change even if the impact of this on a general election outcome is less clear. It’s now likely that any such general election will come later in the year so we still have time to influence the political parties ahead of them finalising their manifestos. But will we be heard. Andy Reed who has taken on a policy advisory role with the Labour Party remains doubtful that our messaging is cutting through despite all our and his efforts.

We struggle with our ability to influence in the political arena nationally and locally particularly when the financial landscape is tough. During the pandemic we had minimal success at convincing the government of the need to support us financially and survival relied mainly on council and operator reserves which are now depleted. The subsequent cost of living and energy crisis again brought limited sympathy focused only on some swimming pools that are still closing at an increasing rate.

Locally the situation looks just as bleak with the latest LGA budget setting surveys revealing the continued crisis in funding with 55% of those councils responding saying they will need to make savings in their sport and recreation provision and 48% saying similar about their parks and open spaces provision. That’s not to say that libraries and culture will fare much better.

One aspect of the elections that really landed with me for the first time was the degree to which the concept of sub-regional elected mayors had grown in significance and just how much of the country is now covered by this new level of policy making, funding and democracy. Listening to some of their acceptance speeches I realised not only the breadth of their powers but also their desire to take even more control of what happens in their places away from central government.

I wrote recently about the ongoing tensions between a national governments desire to keep control of policy, funding and especially delivery and the importance of devolution to local leaders, places and communities. This government has never got the balance right and local government particularly has not only lost much of its funding it has seen its general rate support grant gradually transferred to nationally controlled funding pots such as levelling up and town centre improvement. But watching the results I began to think that momentum may be moving away from the national to the sub-regional and hopefully back to the local. An incoming Labour government is likely to want to expand devolution not only to elected mayors and ICSs but to communities themselves, but as ever will worry about loss of control on delivery. In the future the retention of parliamentary power may increasingly become dependent a governments willingness to ‘let go’ and trust local leadership even when it comes from a different political party. The tension will remain.

If this shift is happening then it brings into question our future lobbying strategy which has to date focused almost entirely on begging the current government for more money and/or less taxation along with the repeated requests to be made statutory justified simply on our? ability to improve peoples health and save the NHS money in the future. We have repeatedly played into the top down agenda often annoying political and professional partners locally and leaving us with little influence in either camp. If the shift is to more devolution we need a new narrative that plays more to this devolved place focused landscape of elected mayors and ICSs as well as councils and communities and we need to develop the local leadership capacity to build trusted relationships to influence better at these levels.

Devolution does have an impact.

As I watched the election results unfold interestingly I received an email from John Oxley sharing a link to a research report which plays directly into this very debate. The report assesses the impact of devolution on local health systems based on the evidence from Greater Manchester. https://www.sciencedirect.com/science/article/pii/S0277953624002454

The research evaluated the impact of devolution on multiple health outcomes using a whole system approach. They estimated the impact of devolution until February 2020 on 98 measures of health system performance identifying which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents.

They found that life expectancy and healthy life expectancy increased more in Greater Manchester than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with wider social determinants of health, including a reduction in alcohol-related admissions. In contrast however the impact on outpatient, mental health, maternity, and dental services was more mixed and adult and child obesity levels particularly in the most deprived areas did not improve showing that continued effort will be required going forward.

Devolution has impacted on improved population health, driven by improvements in health services and the wider social determinants of health. These changes occurred despite the limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.

Most of us will be aware of the impressive work being done by GMMoving and partners to address inactivity and will have seen how this work aligns itself with the policies to address population health and health inequalities under the leadership of Andy Burnham, re-elected over the weekend. I first came across Andy as he transferred from his role of Secretary of State for Culture Media and Sport to Secretary of State for Health when he spoke to a CLOA meeting in Wigan. It was clear then that he got the link between sport, activity and physical and mental health so it’s no surprise that the GM team have been able to build strong relationships with him and position what they do alongside other services and partners across Greater Manchester. Under his leadership it’s no real surprise that the research shows that devolution has lead to improvements in life expectancy and some wider social indicators.

Health inequalities are getting worse.

Contrast this with the new report from Sir Michael Marmot published last week “Englands widening health gap:local places falling behind.”

https://www.instituteofhealthequity.org/resources-reports/englands-widening-health-gap-local-places-falling-behind/read-the-report.pdf

The report by the Institute of Health Equity (IHE) uses data from the Office for National Statistics (ONS), the Office for Health Improvement and Disparities (OHID) and the National Audit Office (NAO), to look at every local authority in England and, for each one, plot levels of health, inequalities in health and cuts in their spending power given that authorities fund many of the services e.g., housing, education and social care, which support or ameliorate the drivers of health inequalities. More than half of authorities saw an increase in life expectancy inequality for both males and females from 2010-12 to 2017-19 – but no authorities recorded a statistically significant decrease.

At a regional level, north-east England saw the biggest gap in life expectancy between the least deprived and most deprived neighbourhoods in 2017-19, at 12.2 years for males and 9.7 years for females, followed by north-west England (11.3 and 9.6 years respectively) and Yorkshire & the Humber (10.4 and 8.5 years). The regions with the lowest inequality were all in the south: London (7.2 years for males and 5.1 for females), the South West (7.5 and 5.6 years respectively) and the South East (7.8 and 6.1 years). North-east England recorded the largest increase in inequality for both male and female life expectancy from 2010-12 to 2017-19.

The report also highlights 17 local authorities with statistically significant increases in inequalities in life expectancy between 2010-12 and the start of the COVID-19 pandemic*.

There were 14 local authority areas with significant increases in inequalities in female life expectancy, and three in which inequalities in life expectancy had increased significantly for males; there were no statistically significant decreases in inequalities in life expectancy for men or women in any of the English local authorities. (See Appendix 1)

For females, these include Kensington & Chelsea in London, where the difference in inequality grew over this period from 6.2 to 11.9 years, Guildford in Surrey (2.8 to 8.0 years), Stoke-on-Trent in Staffordshire (4.8 to 8.9 years), and Rotherham (6.6 to 10.4 years).There was a significant increase for males in Erewash in Derbyshire (up from 4.9 to 9.5 years), County Durham (7.4 to 9.8 years) and Cornwall (4.3 to 6.5 years),

The report further confirms that since 2010 central government cuts to local authorities mean their spending power per head of population had fallen by an average of 34% across England in 2019/20. Based on National Audit Office (NAO) figures, the IHE has calculated that funding from national government to local authorities (e.g., through the revenue support grant) fell by an average of 41% per head of population in England between 2010/11 and 2015/16, and the tax raised by councils themselves fell by 8% per head of population.

?After 2015/16, extra revenue raising powers, including increasing Council Tax, allowed councils to increase the amount raised each year, so that by 2019/20 this amount, per head of population, was 4% more than in 2010/11 in real terms. However, government support per head of population was 58% below that in 2010/11, resulting in overall council spending power per head of population down by 34% on 2010.

?Sir Michael Marmot in launching the report said: “It is no surprise that local authorities are struggling to make ends meet and that people are living shorter lives than they should. If you slash the services that support people then health will be harmed. Levelling up was supposed to provide badly needed funding for the most deprived areas. But it was a derisory amount and, as a result, never going to improve health.” ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

So will more devolution help address the crisis of worsening life expectancy and rising health inequalities. Not alone it won’t. Marmot is right about the need to now invest heavily in public services where they are needed most but how those resources are used will make the real difference. We will also need to address challenges of culture, behaviour and power dynamics, organisational complexity overlaps and duplication, measuring and evaluating impact, whilst acknowledging staff fatigue and burnout. Above all it will require exceptional leadership at a place level.

A new narrative for a new context.

We use to use the phrase “the plates are shifting” when we felt big strategic change was starting to happen. Maybe politically the plates are starting to shift and I suspect we could start to face a very different context over the next twelve months. Sport and physical activity will remain under pressure in the public sector even if the private fitness market is reporting increased numbers and profits. But last week' Active Lives update showed again that inequality in activity is still not shifting despite our efforts to ‘unite the movement’. In response once again simply admitting that ‘more needs to be done’ is not in my opinion a strong enough response from a sector that says addressing inequality is its core mission.

We have to be honest and admit our lobbying to date has been less than effective and focusing on convincing central government to provide more funding to help us with ‘pivoting to health’ then continuing to make the better off fitter is not going to land well with a new government, elected mayors, ICS boards or council leaders. If we are to be taken seriously going forward we must have a new narrative that plays to a different tune. A new narrative must not only come from and be owned by the whole sector as a common purpose but it must be capable of local delivery in places.

It’s not for me to define that narrative but I will suggest what are I think are some of the key ingredients.

• It must play into and support the concept of devolution at a place level and focus on mainly influencing the local.
• It has to acknowledge that we are a small although important cog in changing a much bigger system.
• It must demonstrate how we will help address health inequalities and declining life expectancy if we wish to be a serious player in local health landscapes.
• It will have to show how business models can provide universal services that are proportionate to need and address inactivity within the poorest communities.
• It will need to demonstrate how we will address climate change priorities.
• It has to accept our own weaknesses and address our own culture and behaviour change.
• It has to demonstrate how we will develop stronger local collaborative leadership skills.

We have to acknowledge however that in developing a new narrative we must first address some elephants in our room and we will have some financial asks of a new government. The following three challenges lie at the heart of what often divides us as a sector and undermines our ability to better collaborate locally. We have to resolve these within ourselves before we attempt any influencing of a new government.

The first is the relationship between addressing inactivity and supporting participation in sport. Traditional sport including swimming contributes to only a proportion of overall activity levels but the provision of facilities especially pools is high cost compared to say walking and cycling which appeals to many more people. It’s councils that in the main have provided much of the infrastructure and many working in sport feel the developing focus on health and activity has helped reduce the commitment to sport and recreation as councils can find cheaper ways of tackling inactivity. Health commissioners also find it unattractive to invest in providers who tend to support the already active rather than reach the inactive given the long standing evidence of sports inability to close equality gaps. But there is a danger that the drift away from funding traditional sport leads to activity levels falling if provision is not protected and maintained. There are also real fears and dangers that the loss of pool space seriously damages children’s ability to swim safely, currently a statutory requirement. Any new narrative must set out clearly how we achieve the right balance between tackling inactivity and maintaining sport participation but those receiving public funding for sport must do far more to address inequality.

The second is our reliance on self generated income and the barriers this creates for our poorest communities. Over two decades we have seen the commercialisation of much of public leisure with councils gradually replacing subsidies with returns from private and trust operators. Austerity drove efficiency ever higher but often at the expense of effectiveness as the more deprived communities were squeezed out. The pandemic, energy crisis and cost of living crisis means the situation has got no better. There is a fundamental tension between addressing exclusion in our most deprived communities, helping reduce health inequalities and maintaining the financial sustainability of our facilities. Whilst the sector must itself do more and do better to deliver proportionately to need the government, councils and health partners have to acknowledge as Marmot has recently made clear that to reach those most deprived additional investment is going to be needed. However which providers are best able to utilise this investment, facility operators, sport clubs or locally trusted community organisations will be the challenge which needs spelling out clearly in any new narrative.

The third is the mounting costs of maintaining, improving and modernising the public infrastructure particularly swimming pools. Much of our facility infrastructure is now old and in need of replacement and modernisation particularly if we are to address the energy challenge and meet climate change targets and much is in the wrong place for the communities who need it most. We are seeing new models emerge that are both more efficient and effective but they need capital investment to make them happen. Many new developments are multi service venues often integrating a wide range of accessible public services including health and social care so these models can be easily located in the concept of placed based system change. But we cannot avoid making more capital investment a key ask of a new government, elected mayors and councils. A new narrative cannot avoid such an ask if we are to help reduce health inequalities and address climate change.

Over to you for your response. I look forward to seeing how a new narrative will emerge over coming months.