LGA evidence on Major Conditions Strategy

• The LGA is the national membership body for local authorities. We work on behalf of our member councils to support, promote and improve local government. Our core membership comprises 315 of the 317 councils in England and includes district, county, metropolitan and unitary authorities along with London boroughs and the City of London Corporation.
• The LGA has consistently worked with Government, NHS England and local partners in the NHS, social care and public health to develop the new policy landscape and approach to health and care, aimed at shifting the dial on our growing burden of ill-health and long-term conditions, and the increase in health inequalities. We strongly support a preventative, assets-based approach to health, which recognises that the essential components of good health go far beyond NHS treatment and care.  An assets-based approach supports repeople to make healthy choices and enables them to live healthy, independent and productive lives. If they have health and social care needs, our approach is to provide community-based and person-centred care and support which enables them to live independently and live their lives as they choose.
• The questions in the Call for Evidence are not directly relevant to local government’s perspective on the Major Conditions Strategy and underplay many of the key components we believe are crucial to improving health outcomes and our care and support of people with multiple health conditions. We have therefore set out our views on the best approach to preventing the major conditions from arising, early diagnosis, the effective management of ill-health and providing effective joined-up care and support for people who live with multiple conditions. We provide examples of good practice from councils and their partners in these areas. Our evidence focuses strongly on prevention because we believe that prevention has been overlooked in terms of national priorities and resources.
• We also consider that the questions set out in the Call for Evidence take an overly medical approach to prevention, early identification, and effective management of ill-health. Below, we set out the LGA’s preferred approach and key messages.

• Take a whole-systems, assets-based approach – which reaches beyond the NHS and in which local government, the community and voluntary sector and the community itself are key partners in creating communities which activity promote health and which provide holistic, community-based care and support when people need it. Local government has a vital role to play, not just in planning and providing essential preventative services, but also in addressing the wider determinants of health through their early years support, planning and provision of housing, leisure and recreation, provision of green spaces, environmental protection and contribution to the local economy.
• Join up national Government planning and action – in the same way that integrated care systems are beginning to collaborate at system level and the way that health and wellbeing boards and other place-based partnerships have adopted at place level.
• Prevention and early intervention must be the basis of the strategy – including primary, secondary and tertiary prevention. This must include the vital contribution of local government. And foremost to this approach is tackling the risk factors that contribute to many of the major conditions.
• Health inequalities and addressing socio-economic inequalities must be central – we are disappointed that the standalone Health Disparities White paper was abandoned. Reducing the gap in health inequalities and addressing disparities is crucial to improve the long-term health of our nation. We believe that the decision to embed consideration of health disparities into the MCS rather than have a separate strategy has removed the momentum behind the health inequalities agenda. History shows us that focusing on medical conditions means activity gravitates towards diagnosis and treatment within the NHS and away from prevention and addressing the wider determinants of health.
• A life-course approach is vital – starting from pre-conception, continuing through early, years, adulthood, older age and end of life care, whether focusing on prevention, early identification, or effective care and support.
• Children and young people must be at the heart of the strategy – all of the major health conditions have their roots in childhood so children and young people’s health is important in terms of primary prevention. We recognise that most of the major conditions are primarily experienced in adulthood and later life but care and support for children and young people experiencing one or more of the major conditions must also be considered in the strategy. This is particularly central to supporting children and young people with mental health problems.
• The person must be at the centre of the prevention, early identification and care and support – it is welcome that the Government have committed to a person-centred approach but many of the questions in the call for evidence still focus on specific conditions, rather than the person, who may experience multiple conditions. This is an uncomfortable tension at the heart of the strategy.
• Resources to deliver better prevention and effective care and support – we understand that the strategy will not consider the adequacy of resources available for prevention, early diagnosis and care and support for people with major conditions. Given the financial pressures on public health, local government, the community and voluntary sector and the NHS, it is difficult to see how they will be able to develop new interventions to prevent major conditions from developing without additional resources or redirection of existing resources.
• The importance of mental health – we welcome the inclusion of mental health in the Major Conditions Strategy in recognition of the complex interactions between mental and physical health. We will continue to press for parity of esteem, resources and attention between physical and mental health.

• The strategy will not be effective if it is limited to clinical interventions and the work of the NHS. We are keen to work with Government to ensure that local government partners, who are vital in planning and delivering prevention, care and support, are actively involved in developing the scope and content of the strategy. We need to identify and invest in the factors that make us well and able to maintain our health and independence as well as providing timely and effective care and support when people are in poor health.
• People and communities have assets which determine their health, and these can be built on and strengthened. Looked at from this point of view we can see health as a public good, as something that everyone should work towards and the best attainable health as a human right. We believe this should be emphasised within the strategy and that it should take an assets-based approach to health.  
• We know that, in terms of primary prevention, many of the functions and statutory duties of local government – housing, planning, environmental health, early years support, transport, leisure and recreation, and provision of green spaces – are fundamental to providing a safe and health-promoting environment for communities.
• Improving health for communities can only be done if the social determinants of health are addressed, in addition to the provision of good quality care and action to ensure behaviour change. There is little use in simply treating people for a health condition if the root cause of the health condition is not also addressed. Tackling social determinants includes improvements in housing, ensuring access to good education and good employment, as well as ensuring a health-promoting environment. Each of the factors influencing the social determinants of health can be improved to give an overall improvement in the health and wellbeing of communities.
• We are therefore disappointed that the Call for Evidence does not seek analysis, views and good practice on addressing the wider determinants of health, to stop the clinical risk factors from developing in the first place. The challenge is to address the upstream and socio-economic factors such as poverty, unemployment, lack of educational attainment, poor housing that give rise to high rates of smoking, obesity, stress and anxiety which in turn increase the clinical risk factors for many of these major conditions. Most health problems and inequalities are caused by a complex mix of environmental and social factors which play out in a local area. Councils have a key role to play in addressing the social determinants of health at all levels of local government – children’s services, housing, community safety, culture, leisure, parks, planning, employment.
• Local government and its partners in the NHS, community and voluntary sector have developed whole-systems approaches to addressing a range of risk factors that contribute to poor health and wellbeing. We recommend that these are used to inform the MCS.
• The framing of the Call for Evidence questions focuses on specific conditions, citing only clinical risk factors. The LGA recommends that smoking and obesity are also identified as risk factors. There is a strong role for frontline professionals working in neighbourhoods and communities – care navigators, social prescribers, GPs, pharmacists, public health professionals, social care professionals and local community and voluntary organisations – to identify people who may have increased levels of risk and signpost them to diagnostic and treatment services.

• Bristol City Council’s whole city approach to childhood obesity is long-term, cross-council and all-encompassing. Ambitious targets, set as part of the One City vision, include a halt in the rise of childhood obesity by 2026. By 2050, the aim is that obesity will no longer be a contributor to early death and that children will leave school knowing how to prepare a meal from fresh produce that is available throughout the city.
• London Borough of Brent's life-course perspective to tackle obesity highlights the importance of pre-natal and early-life factors in childhood obesity. Research shows that adult obesity is difficult to treat, emphasising how important it is to work with families to put in place early preventative measures.
• Smoke-free Sheffield: a comprehensive approach to making smoking obsolete The Tobacco Partnership has senior members from across the city including the Council, the NHS, housing, social care, the two local universities, and the voluntary and faith sector. All members share a commitment to a multi-component approach: creating smokefree environments; preventing the sale of illicit tobacco and vapes; supporting smokers to quit; harm reduction; and communicating with the local population and encouraging quit attempts. This approach aims to meet the needs of smokers who engage with services and of the larger population who do not, as well as discouraging uptake among young people.

• Given the cross-cutting and multi-factorial nature of improving health outcomes, it is essential that there is a cross-Government approach to the MCS that addresses the wider determinants of health, led by DHSC but with involvement of other Government departments.
• We recognise that some national policy does make the connections between health and wider social and economic factors. For example, we welcome the fact that one of the 12 missions of the Levelling Up white paper is health focussed:  by 2030, to narrow the gap in healthy life expectancy between local areas where it is highest and lowest, and by 2035 healthy life expectancy will rise by five years. The Levelling up white paper highlights health as a national asset, contributing to resilient communities and a prosperous economy. It also acknowledges that the wide and unacceptable differences in healthy life expectancy between areas also has a negative impact on the economy health of those areas.
• We call on Government to set out how they intend to achieve this ambition. We propose that the Government sets out their strategy for closing the health inequalities gap and improving healthy life expectancy as part of the Major Conditions Strategy. Primarily, Government needs to establish a high-level cross-Government working group to align the plans and strategies of all departments that have an impact on health outcomes and health inequalities, and for the Government to take a ‘health in all policies’ approach that has been adopted by many health and wellbeing boards and integrated care partnerships.
• This would mirror the expectations the Government has of ICSs and especially integrated care partnerships – to develop a high-level, cross-system strategy for improving health outcomes and addressing health inequalities. Local government officers and members are key and willing partners at system level in adopting this ‘health in all policies’ approach. Councils have a critical role to play in achieving the mission set out in the Levelling Up white paper and many health and wellbeing boards (HWBs) have adopted the same approach at place level. Their ability to align local plans and priorities across the factors affecting health and wellbeing would be helped immeasurably if Government also adopted a ‘health in all strategies’ approach.
• The inclusive and system-wide approach also needs to extend to long-term workforce planning. NHS England has a long-standing commitment to publishing a national workforce plan for the NHS. However, this will only go so far in addressing the critical workforce challenges faced by NHS, social care, public health and the voluntary, community and social enterprise sector (VCSE). We need a comprehensive, integrated health and care workforce strategy spanning all professions and sectors contributing to health and wellbeing if we are to improve physical and mental health outcomes, and embed a person-centred approach that focuses on people rather than individual health conditions.

We welcome the Government’s commitment that prevention and early intervention will be a strong feature of the Major Conditions Strategy.  For too long, prevention has been overshadowed by clinical treatment. Rather than waiting for people to become ill, we all agree that the best approach is to support people to make healthy choices, so they do not need health and care services and to intervene as early as possible to identify and mitigate risk factors. This calls for a significant shift in focus from treatment to primary, secondary and tertiary prevention. Local government has a key role to play in all three levels of prevention.

Primary prevention

Through its public health teams and wider plans and strategies, local government has a leading role in taking action to reduce the incidence of disease and health problems, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk population groups. Below we have included just a small sample of case studies from local government on their action on primary prevention, including addressing the causes of chronic respiratory diseases, weight management, promoting physical activity and support smoking cessation. The LGA website contains numerous local case studies of initiative to help people maintain a healthy weight, promote physical activity, support smoking cessation and support people with drug and alcohol problems. Read more case studies.

• Hertfordshire County Council has taken a whole systems approach to child obesity that is built on ten pillars of action. The ’10 pillars of action’ being:  a healthy environment, engaging with neighbourhoods and communities, a ‘first 1000 days’ approach - from the start of pregnancy to age two, schools and workplaces, focusing on young people, focusing on children and adults with special needs, helping people to regain a healthier weight, learning from research, evaluating, digital technology and behavioural science. It includes a successful weight management service that families can refer themselves to, an innovative active school travel plan that discourages car drop-offs and ten “healthy hubs” across the county. In terms of outcomes, 76 per cent of those who enrol in the self-referral programme complete the course and 89 per cent of them either reduce or maintain their weight.
• Wigan Borough Council has an integrated health and wellbeing offer to tackle childhood obesity where leisure services provide a complete programme of education, prevention, early intervention and treatment for children and young people. Children and young people have increased their physical activity levels since enrolling in the programme.
• Coventry City Council focused on supporting minority ethnic women during and after pregnancy to help them manage their weight. It offers education, support and advice on breast feeding, introduction to solid foods, portion sizes and healthy eating through eight family hubs. More than 90 per cent of those who were tracked through the programme were still breastfeeding at 6 to 8 weeks.
• Birmingham City Council aims to transform the city’s food system to supports all its citizens, organisations and businesses through four key aims: grow the Birmingham food revolution; build a sustainable, ethical and nutritious food system and a thriving economy; build more resilient communities that support those who most need it, and mitigate food insecurity; and empower citizens to consume a sustainable, ethical, healthy and nutritious diet. Its eight-year strategy is supported by a wide range of stakeholders including the Council, food poverty organisations, the CVS, schools and nurseries, universities, food producers and distributors, caterers, food businesses and dieticians.

• Since 2017 East Riding has supported a team of community link workers based in GP surgeries to offer social prescribing to local people. In its first 16 months of operation, it saw over 3,800 people. The Exercise on referral scheme and the Live Well scheme also enable GPs to refer people directly for exercise on prescription. In one year, 1,700 exercise-on-referrals were made as well as 258 Adult Live Well referrals and 230 Young Live Well referrals. An evaluation of the programme found that 79 per cent of referees completed the programme and over half of them achieve at least a five per cent weight loss.
• Eastleigh Borough Council is increasing physical activity for girls and women through a sports promotion campaign in partnership with This Girl Can. The campaign which ran for a year from January 2022 included a subsidised women-only Couch-to-5K programme, Boogie Bounce targeted at women and girls new to exercise classes, discounted gym membership and workshops to promote techniques to overcome barriers to participating in sports and exercise.
• In 2018, the Active Gloucestershire’s We Can Move Programme worked with black and minority ethnic communities to set up activities, including women-only exercise classes, walking groups, climbing and cycling groups. The cycling group helped over 30 local women from black and minority ethnic communities to ride a bike and nine others have become cycling instructors. Before the pandemic, nearly 300 women participated in different activities. Since the end of the pandemic other initiatives have been set up, including an outdoor gym, couch-to-5K running groups and a community garden club.

• Sheffield’s has a five-year strategy to make smoking obsolete, by reducing smoking prevalence to 5 per cent or less, achieving a smoke-free city by 2030. The aims of the strategy are to improve people’s health and wellbeing, lift people out of poverty, reduce health inequalities, build resilience in health and social care systems, and boost the local economy. The Partnership includes senior leaders from the Council, the NHS, housing, social care, the two universities, the voluntary and faith sector. Their approach includes: creating smokefree environments; preventing the sale of illicit tobacco and vapes; supporting smokers to quit; harm reduction; and communicating with the local population and encouraging quit attempts.
• There has been a fall in smoking prevalence from 17.6 per cent in 2017 to 13.3 per cent in 2021 and the number of smokers in the city has fallen by 22,000. Over this five-year period the number of smoking related deaths from heart disease, stroke, COPD and lung and oral cancer, and the prevalence of heart disease has fallen. In addition, an estimated £100m previously spent on tobacco is now back in the pockets of local families, supporting the local economy.
• Salford’s Stop Smoking Service has been supporting people to quit since 2004. It works in partnership with the CURE Project, Greater Manchester’s programme for tobacco dependency treatment in acute care. The CURE project is a secondary care treatment programme for tobacco addiction. It aims to offer nicotine replacement therapy and specialist support for the duration of their admission and after discharge to all smokers who are admitted to secondary care. Improvements in the referral pathway increased the quit rate among patients discharged to the community Stop Smoking Service from 34 per cent to 44 per cent in six months. Between 2019/20 and 2021/22 the number of successful quitters seen by the community Stop Smoking Service increased by 87 per cent from 366 to 683.

• The Women’s Support Centre is based in Woking and supports women from all over Surrey who are at risk of becoming involved in the criminal justice system. Often, substance misuse is a major risk factor, alongside insecure housing, mental health issues, domestic abuse and poverty. It provides one-to-one support and advocacy, facilitate support groups and refers women on to more structured treatment programmes.
• The Edge Café in Cambridge, set up in 2017 by the Cambridge County Council substance misuse service, supports people recovering from substance misuse and those with mental health problems by running group activities such as yoga and Tai Chi, Alcoholics Anonymous and Narcotics Anonymous sessions, carers support, and support for survivors of domestic violence. They also provide opportunities for volunteering, which helps build peoples skills, confidence and community connections.
• The Outside Edge Theatre Company, supported by local authorities in West and North London, offers free drama activities to help people affected by addiction to improve wellbeing and prevent relapse. In 2020, they delivered 228 free drama activities and produced 12 performances, involving 276 people. Using the former National Treatment Agency’s value for money tool, the local return on investment on drug treatment and recovery programmes estimates that for there is a return of over £6 for every £1 invested. 94 per cent of service users reported that the activities supported their recovery and 91 per cent reported not using substances in the past month.

Secondary prevention

• Secondary prevention focuses on the diagnosis and identification of the initial stages of disease and ill-health before more serious symptoms and associations develop. For example, identification and management of type-2 diabetes to help people manage their condition and minimise the risks of deterioration.
• This requires local government professionals in public health and social care to collaborate with their partners in the community health services and the community and voluntary sector to put in place accessible and community-based supports and interventions. Often these initiatives focus on ‘hard to reach’ groups in the community who experience barriers in using mainstream services. 

• Local authorities commission health check and these have a vital role to play in secondary prevention. There are many of examples of local government good practice in Checking the health of the nation: implementing the NHS Health Check programme

More recent examples of good practice can be found by following the following links:

• Andover, Hampshire: Health checks at a town centre hub to relieve pressure on NHS services
• Newcastle: Encouraging cervical screening uptake in ethnic minority women and trans and non-binary communities
• East Riding: a Clinic on Wheels - the Importance of Outreach Work

Tertiary prevention

• Even if we are effective in reducing the incidence of long-term conditions, many people will still be affected by them and will continue to need care and support to manage long-term, often complex and multiple health conditions. We welcome the fact that the Major Conditions Strategy will address tertiary prevention. The LGA strongly supports enabling people with long-term conditions to live their lives to the full, within their capabilities. Many people with significant and multiple conditions will also be supported by adult social care to maintain their health, wellbeing and independence. For this reason, it is crucial that social care is at the heart of the Major Conditions Strategy.
• In November 2018, the LGA published our own vision of the future of adult social care, which built on the focus on the Care Act 2014 on the promotion of a person’s wellbeing. Promoting the wellbeing of people with long-term conditions requires a broader plan of action across all relevant council services, such as housing, transport, leisure and green spaces, with the wide range of support provided by the community and voluntary sector.
• Furthermore, we need to develop this approach in partnership with people with lived experience of long-term conditions who draw on care and support. The Making it Real framework developed by Think Local, Act Personal (TLAP) clearly articulates what good, personalised and community-based support looks like from the perspective of the person living with long-term and multiple health conditions, rather than taking a disease specific approach.
• In April 2023, the Government published Next steps to put People at the Heart of Care, which set out its strategy for implementing the Government’s White Paper. The implementation plan includes key activities to help people who draw on adult social care to remain independent at home, including a new Older People’s Housing Taskforce to deliver more choice in suitable housing. It also announced additional funding for people to make adaptations and repairs to their homes so that they can stay independent for longer.
• While we welcome the focus on supporting people with long-term conditions to remain in their homes, we feel much more could be done to realise the aspirations of the Care Act 2014 to have a stronger focus on promoting wellbeing and independence for people who need social care support. We are disappointed that the Implementation Plan significantly waters down previous Government commitments to adult social care funding. Only £700 million of the previously announced £1.7 billion has been confirmed to support the adult social care workforce. Effectively, this funding has been halved, though Government has said that the unallocated funding will remain for adult social care. We have called on the Government to ensure that this funding must continue to be ring-fenced for social care and given to council without additional conditions.

• Primary, secondary and tertiary prevention are all essential to the Major Conditions Strategy. But there has been consistent lack of investment at national level in prevention. Explicit and additional investment in prevention is required. It is more cost-effective to prevent ill-health than treating major conditions once they have developed. Many mental health and physical health conditions have their roots in childhood, so children’s mental and physical health and wellbeing needs to be a key focus in terms of prevention, early identification, and intervention, and providing treatment and support.
• The Government should introduce a Prevention Transformation Fund. This would enable some double running of new investment in preventative services alongside ‘business as usual’ in the current system, until savings can be realised and reinvested into the system.
• The Government must provide long-term resources to public health. It improves the health of society, advances equity, and fosters economic resilience. It is makes fiscal sense to invest in public health to help reduce the long-term cost of treatment and to maintain a sustainable health and social care service. We have called on the Government to increase the ring-fenced public health grant in line with increases in funding for the NHS.
• With regard to people with multiple conditions, adult social care is a vital component of the joined-up care and support that enables them to live full lives and helps them manage their conditions, we need immediate and urgent investment to shore up adult social care and ensure its future sustainability. The LGA has called on the Government to provide £13 billion to stabilise the fragile social care provider market, to fully implement the full range of statutory duties with regarding to prevention and promoting wellbeing set out in the Care Act 2014, and to tackle unmet and under-met need that has intensified since the pandemic. 

• We understand that the now shelved Health Disparities White Paper will be incorporated into the MCS. We are concerned and disappointed at the abandonment of a separate strategy to address the widening disparities in health. That said, we are keen to work with Government to ensure that identifying the impact of and addressing the effects of health inequalities is central to the MCS.
• We know that good health remains out of reach for far too many people in the UK, and that deep inequalities in health between the poorest and wealthiest are widening. We recognise the Major Conditions Strategy will aim to address regional disparities in outcomes but focussing on outcomes alone will not be enough to close the almost 20-year difference in healthy life expectancy that exists between the most and least deprived. That said, we are keen to work with Government to ensure that identifying the impact of and addressing the effects of health inequalities is central to the MCS. Only by considering the wider determinants of health will efforts to help people live longer, healthier lives succeed.
• Consideration of women’s health needs to be fully embedded in the strategy. It is increasingly recognised that women’s health issues have not been given adequate consideration in medical research and practices even though women and girls make up 52 per cent of the population. In relation to the major conditions to be included in the strategy, there has been a lack of research on gender impact on disease.
• It is crucial that the strategy considers the specific needs for women in prevention, early diagnosis and treatment, and care and support of the major conditions, as well as the interactions between major conditions and other health conditions that are disproportionately experienced by women.

• In Nottinghamshire, the council and its partners are working together to improve access to affordable and healthy food. Families with young children are being supported with the cost of living through a network of FOOD Clubs which provide more affordable access to healthy ingredients. The FOOD Clubs model provides families with a nutritious mix of fresh and dried foods and encourages them to learn about healthy eating and cooking. Families contribute £3.50 a week and in return are provided with a food box worth up to £15. This saves at least £300 per family over six months and reduces food waste.
• A quarter of children in England have tooth decay by the age of five, but in Bradford this rises to around 40 per cent. To tackle the issue, the council has commissioned a specialist team to promote good oral health. It works in primary schools, runs community events and now offers support to private nurseries. The team of dental nurses and oral health improvement practitioners delivers a rolling programme of fluoride varnish aimed at children aged two to four, with fluoride varnish applied to children’s teeth twice a year between their second and fourth birthdays. Over 18,000 fluoride varnish applications are applied each year with over 90 per cent of parents engaging with the programme.

• The interaction between demographic, socio-economic and physical and mental health factors is complex but there is no question that excluded groups experience more poor physical  and mental health than the wider population. These include people with serious mental health conditions and people with learning disabilities and autistic people.
• Councils have a critical role to play in reducing mental health inequalities and enhancing inclusion and cohesion within their communities. There are clear links between poor mental health and health and racial inequalities. Children from low-income families are four times more likely than those from the wealthiest households to have a serious mental health difficulty by the time they leave primary school. Unemployment and poverty are strongly associated with poorer mental health and a higher risk of death from suicide. And rates of mental health problems can be higher for some black and minority ethnic groups than for white people.
• Councils are key to identifying and addressing the intersectionality between health inequalities, protected characteristics, socioeconomic deprivation, and poor mental health, however, resources limit the work that councils can do. The Centre for Mental Health in its Commission for Equality in Mental Health recommended that councils need an urgent funding boost to coordinate action to pursue mental health equality. We need recurrent long-term funding in councils so that children’s, adults, and public health services can meet existing, new and unmet demands to combat mental health problems.
• The pandemic has exacerbated existing inequalities and has led to an increase in mental health needs and the demand for mental health services. People living with mental health conditions have reported losing informal networks and essential services during the lockdowns, and there is evidence that deaths from COVID-19 have been three times higher than average for people with schizophrenia.
• The LGA has produced a number of case studies which highlight examples of councils working to address health inequalities and mental health and how COVID-19 impacted people's mental health.
• Research has shown that on average, people with a learning disability and autistic people die earlier than the wider population (Learning from Life and Death Reviews of people with a learning disability and autistic people)
• Sixty-three per cent of people with learning disabilities die before reaching the age of 65, compared to 15 per cent in the general population (New report examines why people with learning disabilities continue to die prematurely)
• Inequalities are exacerbated for people with a learning disability from black, asian and minority ethnic (BAME) groups, who were six times more likely to die from COVID. (Double Discrimination: The Healthcare Inequalities facing People with a Learning Disability from Black, Asian and Minority Ethnic Communities) Councils play a key role in reducing the inequalities people with learning disabilities can face through commissioning services to develop their independence and communication skills and promote good health. You can read case studies about councils that are addressing health inequalities: Health inequalities: Learning disabilities case studies
• The national Learning from Life and Death Reviews of people with a learning disability and autistic people (LeDeR) programme is working to tackle some of the ways that people with a learning disability and autistic people are treated differently in the health and care system.
• An example of good practice is the LeDeR Managing Deterioration Programme: 'Good Health, Good Lives' for people with a learning disability. West and East Midlands ADASS (Association of Directors of Adult Social Services) with Herefordshire County Council, Lincolnshire County Council Nottinghamshire County Council and Walsall Metropolitan Borough Councils and supported living providers in the council areas developed a pilot project to work with supported living providers and partners in the NHS to help social care staff to identify the signs that someone with a learning disability is deteriorating and work with NHS staff to get the person the care they need in this situation. 

• Councils have a vital role in building the wider determinants of good health and working to support individuals, families, and communities across the life-course, from pre-conception to older age. We need a system wide focus on early intervention and prevention. Intervening early to prevent physical and mental health problems developing, or to treat and support children’s, parents and families before problems progress is essential.
• A life-course approach is just that: it starts with support for parents prior to conception and continues throughout life, including support people at the end of their lives. Helping people to have choice and dignity at the end of their lives cannot be delivered by one agency. The NHS plays a key role, as do hospices and other charitable and voluntary groups. Councils also have a key role to play, both in the delivery and commissioning of key services such as home care and care homes, particularly as increasing numbers of people choose to die at home.

• It is crucial that Government maintains a strong focus on children and young people’s physical and mental health. We are concerned that without an explicit strategy on children’s health, this will be overlooked. Many of the conditions in the strategy are primarily, though not exclusively, experienced by adults so there is a substantial risk that children’s physical and mental health may not receive the prominence it deserves. Furthermore, the strategy must recognise that children have unique and distinct needs, and a separate legislative framework, so that an all-age approach may not address the specific needs and aspirations of children with major conditions.
• The Family Hubs programme should be rolled out to all local authorities, supported by long term funding, providing essential support to families, children, and young people. Good quality early education and childcare can close the disadvantage gap between children from more disadvantaged backgrounds and their better-off peers. This has long-lasting positive outcomes. Education and childcare should be seen as one part of the broader system offer and be integrated alongside wider services such as health visitors.
• There is a range of positive practice shown with integrated reviews which ensures that children and families are seen holistically and involves a range of professionals who know the children well.
• Government needs to support local authorities, the NHS and children’s services providers to improve commissioning relationships so families and providers can get the support that they need, particularly for children with special educational needs and disabilities (SEND).
• The move to place-based delivery through ICS and ICBs is likely to help support children with SEND but delivering for children’s needs to be central to ICB joint forward plans and ICP integrated care strategies. Bringing together different parts of the system means there is the opportunity to provide greater support to children with SEND. For example, health visitors, special educational needs coordinators and speech and language therapists working more closely with providers. This requires investment in the workforce across the system.

• We welcome the Government’s commitment to reflect the key adult social care sector principles of a person-centred, place-based approach and outcome-based approach. The focus should be how all care and support services across health, care, the VCSE sector and other sectors enable individuals to lead their lives as they wish, independent within their own communities wherever possible. A well-trained and valued workforce is essential for high quality care and support and should, therefore, be a key component in the MCS.
• The MCS should look at delivering outcome-focused, person centred care or support in or close to people’s homes. With a focus on self-care and community engagement, so that people can lead healthier, more independent and fulfilled lives. 
  
  Shifting the centre of gravity: making place-based, person-centred health and care a reality
• The Strategy should also recognise an individual communities’ skills, strengths, and networks to enable people to have a more active role in their care; ensure care and support is more personalised; and understand, build on and sustain the assets and networks that exist within communities. It needs to identify creative solutions to improve health and wellbeing and use support outside of traditional or statutory services.
  
  Achieving integrated care through community and neighbourhood working

• It is disappointing that the Government will not consider the need for additional resources to support the implementation of the Major Conditions Strategy. Given the historic underfunding of primary and secondary prevention, the funding challenges in public health and in adult social care, to provide vital care and support to people with multiple conditions, we consider this a major oversight.
• With regard to support for primary and secondary prevention, public health has a major contribution to play in addressing the causes of the major conditions and in supporting people to make healthy choices. The majority of funding for health is tied up in clinical treatment. We recognise that providing additional financial support is exceptionally challenging, especially given the financial pressures across the public sector. But without resources specifically for prevention, we will not see the radical step change required to reduce impacts on the NHS and adult social care. The Government should introduce a Prevention Transformation Fund. This would enable some double running of new investment in preventative services alongside ‘business as usual’ in the current system, until savings can be realised and reinvested into the system.
• The Government must provide long-term resources to public health. It improves the health of society, advances equity, and fosters economic resilience. It is makes fiscal sense to invest in public health to help reduce the long-term cost of treatment and to maintain a sustainable health and social care service. We have called on the Government to increase the ring-fenced public health grant in line with increases in funding for the NHS.
• With regard to people with multiple conditions, adult social care is a vital component of the joined-up care and support that enables them to live full lives and helps them manage their conditions, we need immediate and urgent investment to shore up adult social care and ensure its future sustainability. The LGA has called on the Government to provide £13 billion to stabilise the fragile social care provider market, to fully implement the full range of statutory duties with regarding to prevention and promoting wellbeing set out in the Care Act 2014, and to tackle unmet and under-met need that has intensified since the pandemic.
• We are disappointed that People at the Heart of Care: Adult Social Care White Paper Implementation Plan significantly waters down previous Government commitments to adult social care funding. Only £700 million of the previously announced £1.7 billion has been confirmed to support the adult social care workforce. Effectively, this funding has been halved, though Government has said that the unallocated funding will remain for adult social care. We have called on the Government to ensure that this funding must continue to be ring-fenced for social care and given to council without additional conditions. 

With regard to mental health, the LGA has previously submitted evidence to the 10-year strategy for mental health, LGA submission to the Mental Health and Wellbeing Plan call for evidence. We welcome that the MCS will include mental health in recognition of the complex relationship between physical and mental health and wellbeing. But we remain concerned that the current mental health challenges for children and young people and adults are so significant that they require a specific strategy, albeit closely aligned to the major conditions strategy.

Local government has a key leadership and delivery role in promoting good mental health and wellbeing in local communities. Roles and responsibilities include:

• system-wide local leadership through health and wellbeing boards, integrated partnerships and place-based care and support systems
• public health responsibilities to promote mental wellbeing and prevent poor mental health throughout the life course. Public health also addresses lifestyle issues related to mental health such as obesity, smoking and drug use and has a key leadership role in suicide prevention
• statutory duties and powers related to adult social care and mental health for children and young people and for adults under the Mental Health Act
• the overview and scrutiny of mental health provision
• councils have a critical role to play in reducing inequalities and enhancing inclusion and cohesion within their communities
• provision of wider council services that promote wellbeing such as housing and housing support, libraries, green spaces and commissioned voluntary and community services
• councils also provide or commission information and advice on local services that can offer mental health support. Many of these services are culturally specific, such as advocacy
• councils have responsibilities to their own employee’s health and wellbeing.

It is important to recognise that there are also significant inequalities in mental health. There are clear links between poor mental health and health and racial inequalities. Children from low-income families are four times more likely than those from the wealthiest households to have a serious mental health difficulty by the time they leave primary school. Unemployment and poverty are strongly associated with poorer mental health and a higher risk of death from suicide. And rates of mental health problems can be higher for some black and ethnic minority groups than for white people.

Councils through provision of social care, information and community support have a vital role to play in enabling people who are living with dementia, their families, and their carers, to retain their independence in the community for as long as possible.

Dementia is also a public health issue and there is a key role for councils in taking forward public health responses. Although there are currently no approaches that have been proven to prevent Alzheimer’s disease and related dementias, several risk factors have been identified that can help prevent or delay dementia^[4]. Councils are key to locally promoting a healthy lifestyle to potentially reduce the risk of developing dementia and actively promoting access to activities and wider community facilities for those who have been diagnosed with dementia to support carers and combat loneliness and isolation.

Palliative end of life care should be personalised giving choice and control over the way that an individual’s care is planned and delivered, based on ‘what matters’ to them and their individual strengths and needs. This should be delivered by a system that supports people to stay well for longer and makes the most of the expertise, capacity and potential of people, families and communities in delivering better outcomes and experiences when unwell.

The LGA are signatories of the Ambitions for palliative and end of life care framework.  This framework sets out our vision to improve end of life care through partnership and collaborative action between organisations at local level throughout England.

Many councils already make a significant contribution to end-of-life care in their area. Some examples are available End of life care: guide for councils.