## Foreword

In 2008, I was asked by the Secretary of State for Health to chair an independent review to propose the most effective strategies for reducing health inequalities in England from 2010. In undertaking this review, we are identifying evidence and making recommendations in the key policy areas - the social determinants of health - where action is likely to be most effective in reducing health inequalities. These are:

- early child development and education
- employment arrangements and working conditions 
- social protection
- the built environment 
- sustainable development 
- economic analysis
- delivery systems and mechanisms
- priority public health conditions 
- social inclusion and social mobility. 
 In every single one of these areas, local government has a significant role to play in working with the NHS and other partners in improving health. The biggest area of local government spending is on education and early years. Local authorities can not only improve and protect working conditions through their environmental health role; they can also contribute to the economic development of their areas and, in almost every area of the country, are themselves among the largest employers. In collaborative working with other key players, they can develop and implement strategies towards the sustainable development of the communities they serve. They can be part of the safety net that protects and supports people who need benefits and social services. 

Through their planning powers, management of traffic, parks and open spaces, leisure and cultural services, they can contribute to the quality of the built and social environment. They have specific duties and powers to promote equality and social inclusion and social, economic and environmental well-being. They work in partnership with the NHS and other agencies such as the police to support public health. In short, they make a very important contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age. 

No review of health inequalities and measures to reduce them in this country can afford to ignore the role of local government. I hope, therefore, that this timely publication will encourage elected members and council officers to reflect on their role in reducing health inequalities and creating the conditions for people to lead flourishing lives and to contribute to the review. I hope also that it will act as a catalyst for others both in the NHS and in government concerned with health, to explore the enormous potential in working alongside local government in tackling what I and others have called 'the causes of the causes' of health inequalities. 

Professor Sir Michael Marmot Chair of the World Health Organisation Commission on Social Determinants of Health Chair of the Strategic Review of Health Inequalities in England post-2010

## Editor'S Introduction

"This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But... it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place." 
(WHO Director-General Dr Margaret Chan, at the launch of the final report of the Commission on the Social Determinants of Health). The social determinants of health have been defined as: "the socio-economic conditions that influence the health of individuals, communities and jurisdictions as a whole. These determinants also establish the extent to which a person possesses the physical, social and personal resources to identify and achieve personal aspirations, satisfy needs and cope with the environment." 
(Raphael, 2004)
The publication in 2008 of the World Health Organisation (WHO) Global Commission on the Social Determinants of Health report and the subsequent commissioning by the Secretary of State for Health of the Review of Health Inequalities Post-2010 in England (the Marmot Review) has raised the profile of the social determinants of health and of the importance of addressing the conditions of everyday life that lead to health inequities. The WHO Commission argues that for reasons of social justice, action to achieve health equity is imperative. It says that attempts to reduce health inequity must be predicated on addressing the wider social and economic determinants, such as levels of education, economic status, and power relations. In order to address health inequalities it is necessary to address inequities in the way society is organised. "This requires a strong public sector that is committed, capable and adequately financed. … In a globalised world, the need for governance dedicated to equity applies equally from the community level to the global institutions." (World Health Organisation 2008) The diagram below shows the widening circles of influence on people's health. These circles are, of course, interpenetrable. For example, your lifestyle 'choices' are influenced, even to a large extent constrained by the social, economic and environmental conditions in which you live, as the quotations from Chan and Raphael acknowledge above. Even the difference made by your gender or your age or hereditary factors relating to your ethnic origin will be influenced by the kind of society or community you live in - how it treats older people and women, whether it understands and responds to the health needs of people whose ethnic group is in a minority in that society, and so on. And, of course, people, individually and collectively, influence the circles by the personal and political action they take and the choices they make. To anyone who knows even a little about the work of local government, it will be clear that local government must be part of the 'strong public sector' invoked by the WHO Commission. The actions of local authorities have an influence, sometimes big, sometimes small, in every one of the circles illustrated below and therefore on the health of their residents. The lower half of the diagram shows only some of the local government activities that impact on the social determinants of health in each one of the circles of influence. Some services, of course, such as the planning function, have an influence in more than one circle - in this case potentially impacting on biodiversity, the 'liveability' of the environment and opportunities for physical activity and recreation. Local government can also make an impact on what the WHO calls the "unfair and avoidable differences in health status" - the inequities in health - between individuals, groups and communities. In recognition of the role of local government in health improvement and in tackling the kind of inequities referred to by Marmot, the Department of Health has funded the Improvement and Development Agency (IDeA) to develop a Healthy Communities programme of work which aims to:

- raise awareness among local government elected 
members and officers of health inequalities and the social determinants of health and of the role of local government and its key partners in addressing these
- build capacity, capability and confidence in local 
government to address the social determinants of health
- ensure local government across England is aware of 
the Marmot review into health inequalities and the social determinants of health and is able to contribute effectively to consultation
- disseminate knowledge and learning to all local 
authorities and their partners.
 
This publication is part of that programme. Its purpose is to provide an introduction to and an exploration of health and health inequalities in England and a consideration, through the views of different writers, of the role of local government in addressing health inequalities through action on the social determinants of health. It is illustrated with practical examples and directs readers to sources of further information and support. Many of the case studies that illustrate the text can be found on the Healthy Communities website of the IdeA. The publication takes the form of a collection of articles by distinguished practitioners of public health, academics with research interests in the social determinants of health and health inequities and local government professionals. Some of the articles are deliberately challenging and provocative; some of them present a picture of what is already happening in local government to tackle the social determinants of health; some of them look to what more local authorities could do in the future, either with additional powers or by using their existing powers and remit. The aim of the publication is to reach beyond those elected members and officers of local government with a specific health remit and to engage with a broad cross section of local government, primary care trusts (PCTs) and the partners who make up local strategic partnerships (LSPs). It will be the forerunner to a short series of pamphlets which look more specifically at aspects of, and professions within local government and their role in addressing health inequalities. The articles in the first section explore some of the issues with which local government needs to grapple if it wants to make a positive impact on the health of the citizens it represents and on reducing inequalities in health between different communities of identity and place:

- Professor David Hunter gives an overview of the social 
determinants of health and the potential role of local government 
- Professor Danny Dorling takes apart the much-discussed 
concept of 'place', looking at it with a geographer's eye, and discusses what it would really mean for local authorities to be the 'place-shapers' they aspire to be 
- Mike Kelly and Tessa Moore look at sources of evidence 
to which local government can turn in devising effective interventions and emphasise the importance of local authorities collecting and evaluating their own evidence 
- Professor Alan Maryon-Davis looks at the developing 
roles of directors of public health and other public health professionals as they come almost full circle to take their place at the heart of local government.
Section 2 considers the strategic and operational implications for local authorities on the ground of the issues discussed in Section 1. 

- John Nawrockyi discusses a pioneering course in 
Greenwich which takes literally the mantra that 'health is everyone's business' in the local authority
- Dr Tony Hill describes his experience of seconding the 
whole public health team from the PCT to the local authority
- Martin Seymour looks at practical implications of the 
'Total Place' programme for health, in bringing together 
all the resources for an area
- The final chapter in this section briefly discusses individual 
local government service areas and their potential impact on health and health inequalities. (These service areas will be among the subjects of a forthcoming series of publications from the IDeA.) 
 In Section 3, a number of different, but not necessarily incompatible approaches to the work of local government are considered in relation to their potential role as tools for health. 

- In the most radical and challenging chapter, Professor 
John Ashton asks us to re-imagine traditional approaches to community development, based on experience in the USA which has influenced President Barack Obama. 
- Clive Blair-Stevens explores how marketing approaches 
initially devised in the commercial world can be harnessed 
by local government and its public sector partners to meet health objectives. 
- Charles Loft discusses some of the new and imaginative 
ways in which local authorities are using their enforcement roles in licensing, trading standards and environmental health as tools for health improvement.
- Adrian Davis describes the important and increasing 
use of health impact assessment as a means both of raising awareness of health issues and of evaluating interventions for their effects on health. 
- Su Turner considers the increasingly creative ways in 
which local authority health overview and scrutiny committees are carrying out their work. 
- Finally, there is a reminder that local government is in 
a position to have a direct impact on citizens' health through its role as a major employer across the country.

## The Context For Local Government

At the beginning of the Labour Government's administration in 1997, a shared priority was agreed between central and local government on the need to reduce health inequalities. This priority has been maintained throughout political changes in the control of local authorities and their representative bodies. All the major political parties now recognise the need to tackle health inequalities and the role of local government in doing so. The specific mandate for local government involvement in addressing the social determinants of health has come through various policy documents, including successive public health and local government white papers and the strategy document 'Tackling Health Inequalities: A Programme for Action' and associated reports, culminating in the commissioning of the Marmot Review to look beyond 2010.

At the same time, a number of reviews of health services, including that of Wanless (2002) and more recently, Lord Darzi's (2008) review of the NHS, reported in High Quality Care for All have supported a shift in effort and focus towards prevention of ill health. Similarly, there has been an increased emphasis in policy on social care and support on taking action to prevent people needing services. This policy focus provides opportunities for local authorities and the NHS to work together to tackle the 'upstream' causes of wider social, economic and environmental determinants of ill health and inequalities. 

The concept of local government as a 'place shaper' was developed by Sir Michael Lyons in his influential report, Place-shaping: a shared ambition for the future of local government. Lyons defines place shaping as "the creative use of powers and influence to promote the general well-being of a community and its citizens" (Lyons 2007, p.60). He says that local authorities must use their ability to bring together local stakeholders and develop a vision for their area. From the perspective of addressing health inequalities, it can be seen how galvanising this concept of the local authority as place shaper could be. As Professor Hunter in Chapter 1 puts it, health inequalities bring together a number of complex and intractable issues which demand new approaches in respect of tackling them. Their complexity requires the involvement of many partners, working together to attack the issues on many fronts. And this kind of partnership at the local level requires the kind of vision and leadership that local authorities can provide as place shapers. Partnerships of various forms and at many levels between the NHS, local government and the voluntary sector are now the norm. Every overarching LSP now has a subpartnership with a remit for the health and well-being of the area - although, of course, because of the nature of the wider determinants of health, all of the local partnership bodies have a role to play in health improvement. Over 80 per cent of directors of public health (DsPH) are jointly appointed between PCTs and local authorities. PCTs and local authorities work together on the Joint Strategic Needs Assessments for their areas on which short and long-term objectives for health improvement and well-being should be based. In every local authority area, there are numerous work programmes and individual projects that involve both health, local authority and voluntary sector staff working together, often working out of the same offices. In recent years, there has been an increasing focus on the collection of evidence to inform interventions that are intended to improve health outcomes, as well as those that have a different primary purpose but which are likely to have a health impact. Local authorities, regional public health observatories, the public health directorates of PCTs and university research departments have begun to work together to collect evidence and evaluate interventions. 

Individual health profiles for each area of the country have been developed which give local authorities information about the health of their own residents. They also provide a 'benchmark' from areas with similar levels of deprivation or affluence to their own, against which they can judge progress in their own area towards reducing inequalities between geographical areas of the kind discussed by Professor Dorling in Chapter 2. There is also more data available about health inequalities between different groups, such as men and women, older and younger people, people from different ethnic groups, which enables local authorities to look within their own areas to interventions targeted at improving the health of groups most in need and thereby reducing inequalities. As bodies with specific responsibilities to promote equality and social cohesion and as elected representatives of often hugely diverse communities, local authorities have begun (recently with the support of research led by the regional public health observatories) to understand more about how diversity within their communities relates to health. There is greater disaggregation of data accompanied by increased understanding of the correlation between different factors such as poverty, housing, education and environment and health, including the fact that black and minority ethnic groups, especially those of Pakistani and Bangladeshi origin (being among the most deprived) have the worst health and the lowest life expectancy. Effective and appropriate use of information is one of the themes of this publication. Dorling believes that we already have enough information to indicate some very clear areas in which local authorities could be making inroads in reducing health inequalities - measures to reduce traffic accidents being one example. At the same time, he points to the importance for local authorities for developing a greater understanding of the role that geography plays in inequality. Paradoxically, despite interest in the place-shaping role of local government following the Lyons report, there has also been increased emphasis in addressing interventions to individuals rather than to places. This is partly because of evidence that addressing public health interventions to a whole population can increase inequalities. For example, people from social class v respond less to anti-smoking campaigns than those from social class 1, with the result that such a campaign can lead to greater inequality (albeit in the context of a reduction in overall smoking levels). Interventions carefully targeted at individuals hope to avoid increasing inequality in this way.

Dorling's article is a persuasive argument to local authorities to complement approaches targeted at individual behaviour with a response that also recognises the geographical basis of inequality - an acknowledgement of the interdependence of places and people. This interdependence was referred to by the Prime Minister in his announcement of the Marmot Review for England. 

Gordon Brown pointed out that that "Life expectancy here in London falls by one year for every underground station you stop at from Westminster to Canning Town" and described this as "the geography of inequality, the geography of injustice". This emphasis chimes very well with the place-shaping model for local government. Dorling also points to the importance of using the right geographical units to develop the kind of revelatory maps for which his work is known. And this will no doubt become an increasingly important issue as more attention is given to developing a robust evidence base for health interventions. The importance of evidence and evaluation is the topic of the article by Mike Kelly and Tessa Moore. With colleagues at the National Institute for Health and Clinical Excellence, Kelly has been using what evidence there is on public health interventions to produce guidance for local government and its partners. Kelly and Moore strongly reiterate the importance of local authorities contributing to the nascent evidence base through their own rigorous evaluation of their work. Professor Maryon-Davis also takes up this theme in his article, advocating a marriage of public health specialists' skills in data collection and analysis together with local authorities' strong record of community engagement in developing new evaluative methods. 

Working together to understand their communities' health profiles and their underlying causes, local authorities and their public health colleagues in PCTs have also begun to recognise the changing nature of a population's ill health. Health conditions relating to poor sanitation and overcrowding have, to some extent, given way to conditions arising from poor food, lack of exercise and the cycle of poor life and health chances associated with the children of teenage parents. This means that, as Professor Hunter notes in Chapter 1, to a certain extent, the local authority functions which can potentially impact most on health have also changed. For example, from sanitation and waste disposal to school meals, social care and support, leisure facilities and accident prevention. This is not to say that the former can be ignored - indeed overcrowding is rising and is once again associated with tuberculosis in the east end of London, as Dorling points out. So although there are new areas in which local authorities can have a health impact, they still have to keep an eye on the traditional social determinants of health - to be watchful and active on all fronts. 

There is no doubt that, despite the many activities of local government and its health partners, some of which are illustrated here, there is still huge scope for further work at a local level to tackle the social determinants of health and reduce health inequalities. Most people - even people in local government and even people in public health - still think of the NHS when they think of health services. Part of the purpose of this publication is to help change that thinking, so that local authority councillors, the officers who support them, the health professionals who work with them and the people who elect them will widen their understanding of what really makes people healthy, what really makes them ill and what causes them to die. When we focus on the social determinants of health, rather than the medical cause of some specific disease, we see that local government services are health services. It is no exaggeration to say that without local government, adults and children would die sooner, would live in worse conditions, would lead lives that made them ill more often and would experience less emotional, mental and physical well-being than they do now. Nonetheless, despite overall gains in life expectancy across all socio-economic groups, health inequalities are widening and there is always more that local government can do. The chapters that follow show something of the vast range of possibilities that await those with the imagination and energy to harness local government to the service of the population's health - the public policy issue that most people care most about. 

## References And Further Reading

Barton, H. and Grant, M. (2006) 'A health map for the local human habitat' in Journal of the Royal Society for the Promotion of Health Vol 126, No 6 Darzi, A. (2008) High quality care for all: NHS Next Stage Review final report, Department of Health:  
www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_085825 Improvement and Development Agency, Healthy Communities Website: www.idea.gov.uk/idk/core/page.

do?pageId=77225
Lyons, M. (2007), Place shaping: a shared ambition for the future of local government, Department of Communities and Local Government Raphael, D. (2004) Social Determinants of Health: Canadian Perspectives Toronto, CSPI Wanless, D. (2002) Securing Our Future Health: Taking a Long-Term View, HM Treasury: www.hm-treasury.gov.uk/
consult_wanless_final.htm Whitehead, M. and Dahlgren, G. (1991) 'What can be done about inequalities in health?' *The Lancet* 338 pp1059-1063 World Health Organisation (2008), Closing the gap in a generation: Health equity through action on the social determinants of health: www.who.int/social_determinants/
thecommission/finalreport/en/index.html Website of the Strategic Review of Health Inequalities in England Post 2010 (Marmot Review): www.ucl.ac.uk/gheg/ marmotreview