Interview

Sheffield: our city, our health

What exactly is Our City Our Health? could you explain a bit about what makes it special?

Paul Snell: It is an attempt to obtain - and synthesise as far as possible into an agreed city health plan - the views of all Sheffield residents and organisations on how Sheffield health could be improved and what they can contribute to it. The biggest challenges are obtaining the views of the least articulate, bridging the communication gulf between those of different cultures and viewpoints and getting such a perspective to feature in reality on everyone’s agenda despite the ‘elbowing-out’ pressure of ‘in-house’ agendas. It’s special because I doubt if it has been tried before in quite so ambitious and comprehensive a way.

Lee Adams: Yes, it’s really our attempt to adapt the Health For All approach of targets and make them realistic, appropriate and accessible. We have tried to set out suggested health goals for various population groups, what influences health for these groups and what might be done to improve health and reduce inequalities. Over and above this, we have included in a ‘Support For Health’ section aspects of life which have profound consequences for health and which present challenges; for example, environment, products and leisure, income. A main difference between Our City Our Health and Health For All targets is that we include objectives around prerequisites for health.

Liz Jayne: In essence, Our City Our Health is an exciting and innovative consultation process which by emphasising the challenges mentioned by Paul, is a precursor to the City Health Plan. This consultation is informed by a comprehensive discussion document highlighting key areas which support health, the particular health experiences of groups in the population and the different approaches which will be needed to improve health and tackle health inequalities.

A range of other materials have also been produced to encourage the debate about health priorities in the city, for example a summary document and translations, a tape/slide show and an exhibition. To ensure discussion across the city, 250 facilitators have been trained to take the debate into workplaces, community groups, schools, and so on. The role of the facilitators is critical to broadening the consultation process coming as they do from numerous backgrounds, such as senior managers in statutory bodies, staff from the Polytechnic, paid and unpaid workers in a range of voluntary and local community groups.

But will all this really make a difference to the health of ordinary people in Sheffield? How sure are you that all of this effort will have been worthwhile in health terms?

PS: No-one can be sure of anything! But since people’s health only means anything in terms of what is important to them, and since it is determined by a whole host of factors, including their own individual and corporate contributions (positive and negative), no other approach has the same potential. Our job is to design and implement a mechanism to realise as much of this potential as possible. Time will tell how far we succeed, but it is not just a one-off: a major function is to start a ball rolling that can develop thought/debate/feedback/collaborative action more and more.

LJ: Inevitably assessing improvements in health in Sheffield will be a complex and long-term task. The mechanism, or process, mentioned by Paul will be central to the success of the City Health Plan. Within the plan itself (which will be drawn up by spring 1993) we will be incorporating an on-going community participation strategy alongside monitoring and review procedures. Assessing health gain and changes in mortality and morbidity rates will provide us with a longer term indication of health improvements. There is a lot of work to be done developing indicators, especially those based on assessing health gain in terms of well-being.

LA: You always have to have some faith in public health and health promotion work. More importantly, you have to have a vision. By harnessing partner agencies’ commitment to Healthy Sheffield and Our City Our Health we will ensure agencies listen and respond to people’s views and needs. At the same time, by working with people themselves we will help them express views to agencies. It’s easy to be pessimistic, as the task is so huge. But Our City Our Health and Healthy Sheffield have a momentum now that is exciting; also we shouldn’t forget that the process of participation can be health promoting in itself. The whole initiative is making a difference already.

Inequalities in health, and in access to health services, seem to be an intractable problem, and may even be getting worse nationally. How will Our City Our Health attempt to tackle this issue, which goes well beyond health and social services?

LJ: Challenging inequalities in health is a central concern of Healthy Sheffield. There are two main elements which attempt to tackle inequality: adopting a community development approach to the Our City Our Health consultation ; and basing our work on a broad social model of health. Community development ensures the most marginal groups in society become priorities for Healthy Sheffield and we hope to develop their confidence and skills which will help in developing more appropriate service provision. Adopting a social model of health, which recognises the social, environmental and economic as well as individual/personal issues which affect health, helps to highlight the immense range of factors which influence health and often perpetuate inequalities.

LA: There is much more we can do locally, for example, by targetting services more appropriately; by purchasing innovative provision which seeks to empower rather than disempower people; by working jointly to pool agencies’ resources. The health authority has a key role as advocate to other organisations - for example, to advise the council about their services and effects on health. We also need to inform government and national and international agencies about their policies and practices and how they affect health in Sheffield. A number of people locally took part in a BBC Radio programme, File On 4, which considered Wilkinson’s work and its implications and how, for example, community projects like our ‘Heart Of Our City’ were attempting to work with local people on fundamental issues.

PS: The two parts to this question are separate. Inequalities in health arise largely from inequalities in the resources/risks/opportunities which people enjoy. We do, of course, need a national strategy to deal with such inequalities: if The Health Of The Nation is to follow through its own logic it will address this. But even within any national strategy - or lack of one - there are great opportunities for local manoeuvre. So far as inequality in access to health services is concerned, there are even greater opportunities to improve this locally, in making services appropriate, accessible and acceptable to all groups. This certainly works within serious national limitations, such as the profoundly regrettable dental charges.

Our City Our Health has come to fruition in a time of tight control of public - and especially local - expenditure, and also at a time when many would argue that the important changes needed to improve health are national, rather than local. Does the national context impose constraints on what Our City Our Health can do to improve health?

LA: Of course, in terms of national and also increasingly international policies and practices. Legislation, the tax system, the amount of expenditure on health, welfare, education, environment, housing - all these affect health in Sheffield. Our City Our Health addresses these issues throughout, but also has a chapter in the ‘methods’ section on national and international advocacy. We suggest that we link to appropriate organisations at national and international levels who are concerned to improve health, establish stronger contact with other Health For All initiatives, try to introduce a health perspective into any bodies to which local organisations belong, improve contact with central government departments, the EC and WHO, encourage local politicians to become more involved in health issues, establish local campaigns and advocate at national level and also - very important - encourage better media coverage of health.

PS: The national and international context naturally affects - positively and negatively - the potential for local action in any field, not just health. As Lee says, Healthy Sheffield will seek increasingly to influence this context. But there remains great potential for achievement in the local room for manoeuvre which the wider ‘scene’ still leaves.

LJ: Any initiative such as Our City Our Health has to work within the context it finds itself and is in part a product of that context. Major organisational and policy changes, especially within the NHS and local authorities, for example the NHS and Community Care Act, Education Reform Act, Children Act, have inevitably had an impact on organisational involvement in Our City Our Health, both positively, for instance, encouraging collaboration and user involvement, and negatively in terms of lack of time available to organisations to spend on initiatives not directly related to new statutory responsibilities. By working, where possible, at national/international levels as well as locally, Our City Our Health seeks to galvanise support and develop opportunities for improving health wherever possible.

What do you, personally, see as the strengths and weaknesses of this approach to public health? What would you like to see happen next with the project?

LJ: Our City Our Health is an exciting approach to improving public health which has captured the interest of the city. I believe its strengths emanate from the broad and rigorous analysis of the factors affecting health on which Our City Our Health is based. This analysis acknowledges the complexity of our health/sickness experiences and firmly indicates the necessity of placing health at the top of everyone’s agenda especially in those organisations which traditionally have seen themselves outside the ‘health’ areas. One of the greatest potential difficulties in Our City Our Health is maintaining its collaborative approach. Turning ideas into action is never easy, especially when working across a range of institutional cultures and organisational frameworks. Developing and implementing a public health strategy at a supra-strategic, city-wide level will inevitably be a major challenge for everyone in Sheffield.

LA: People often ask why Healthy Sheffield has developed when other similar projects have had difficulties. There are two advantages in Sheffield: one is that the boundaries of the council, health authority and FHSA are co-terminous; the other is a genuine commitment by all the partner agencies to the principles of Healthy Sheffield. This commitment has enabled us to move beyond rhetoric. As Liz says, promoting change in a climate where most partner agencies are going through major organisational changes and many are facing financial constraints is very challenging. It is also challenging to try to get people to view ‘health’ differently, as more than illness, as something that everyone is responsible for, and so on. You have to have a great deal of trust and mutual respect between partners for this approach to work. I guess I really believe in its strengths; I have difficulties seeing any weaknesses! I suppose it’s a lot easier to write a City Health Plan and not consult on it, and quicker!

PS: I think Lee and Liz have said it all. I don’t think this approach has any real weaknesses, though it certainly should not be adopted without an open-eyed realisation of the inevitable demands and difficulties. The soft option would be to rely on the views of the most vocal - eg doctors and pressure groups. The decision to go beyond this, and actually seek the views and experiences and contributions of the widest possible range of people and groups, requires great organisational effort and a willingness to take on board a diversity which will make synthesis into a ‘consensus plan’ a challenging task. I suspect, however, that the underlying concerns will show less disagreement than one might anticipate.