ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express

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ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
The Mayoral Health Commission

- the platform to a
healthier Liverpool
ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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
                 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
ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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

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

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ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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
ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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.

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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
    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;

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ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
•   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.

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ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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
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
ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
       1:Projected population change in Liverpool between 2012 - 2021                                                                                                                                                                                                     population experiences poor mental health,              alcohol-related treatment, the equivalent
                                                                                                                                                                                                                                                                          compared to around one in six across the North          of 64,750 visits per year. However, only 6% of
                                                                                                                                                                                                                                                                          West. Mental illness is associated with reduced         emergency departments in the UK offer alcohol
                                                                                                                                                                                                                                                                          life expectancy of between 15 to 20 years3              harm-reduction interventions to patients aged
              10%                                                                                                                                                                                                                                                         .                                                       16 years or under. The Centre for Social Justice
               5%                                                                                                                                                                                                                                                                                                                 put Liverpool sixth amongst local authorities in
                                                                   15-19 20-24 25-29 30-34       40-44 45-49 50-54                         75-79
                       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
                      -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
                                                                                                                                                                                                                                                                          burden of expenditure on the City of more than          males admitted5.
                                                                                                                                                                                                                                                                          £228 million per year, representing an average
                                                                                                                                                                                                                                                                          spend of £512 for every man, woman and child.           1.8
                                                                                                                                                                                                                                                                          For those under 18 years of age in Liverpool,           The incidence of cancers is significantly higher
          -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

                                                                                                                                                                                                                                                                                                                                  adults claiming out of work benefit compared

                                                                                                                                                                                                                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

         60                                                                                                                                          60                                                                                                                   years report binge drinking and drunkenness             Association property1.

                                                                                                                                                                                                                                                                          more than boys. Binge drinking is also a key
    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
     Sheffield                                        Bristol
                                                    Sheffield                                                                                                                                                                                                             alcohol related harm. Evidence suggests a               over the age of 65 years. The most common
    SheffieldStandardised Rates per 100,000 population    , all ages
       Leeds                                          Leeds                                                                                                                                                                                                               strong association between heavy episodic               primary need group is physical disability,
                Leeds                                                                                                                                     Leeds                                                                                                           binge drinking and violent youth offending.             followed by mental health, inclusive of
          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
        Newcastle                                                                                                                                   Nottingham
                                                                                                                                                     Newcastle                                                                                                            negative health and social outcomes including           3,000 service users8.
                     Newcastle                                                                                                                       Newcastle
                                                                                                                                                     LIVERPOOL                                                                                                            accidents, physical and mental health
          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
                                                                                                                                                                                                                                                                          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










                                                                                                                                                                                                                                                                          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
ALL CHANGE - the platform to a healthier Liverpool - The Mayoral Health Commission - Liverpool Express
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
                                                                                                                                                                                                                                                                                                                                     An overview of the main causes of death in                  real terms and continued increases in demand is
                                                                                                                                                                                     Poisoning           Transport
                                                                                                                                                                                                                                               41                      Stomach and                                                   Liverpool can be seen in figure 4.                          demonstrated in Figure 5, compiled by the widely
                                                                                                                                                                                                                                                                      digestive organs
                                  Senility without mention of psychosis                                                     Blood disease and
                                                                                                                                                     Exposure to smoke,
                                                                                                                                                       fire and flames
                                                                                                                                                                                                                              Colon cancer
                                                                                                                                                                                                                                                                                                                                                                                                 respected Nuffield Trust. This identified a potential
                                                                                                                             immune system
2. 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.

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.

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
  • 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 19
3. 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 21
Healthcare                                            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 23
engagement 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.

                                                    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 25
4. Findings                                           the patient rather than managed round the
                                                      budgets of each participating organisation.
A common agenda
                                                      It was abundantly clear that health and well-
                                                      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.

                                                      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
                                                      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
The challenge of transforming the health of
the people of Liverpool is enormous. Witnesses
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.
                                                      This, in turn, necessitates an unprecedented
                                                      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

                                                                  Report of the Mayoral Commission 27
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