Population health in Greater Manchester

Overview

• Greater Manchester (GM) has been the ‘poster child’ for devolution in England, and alongside it, in the health world, the leading light in efforts to improve population health at scale. This report shares the details of that journey, explores how GM has approached improving population health, and looks at both its successes and challenges.

• The evidence suggests that the focus on population health in GM is starting to pay off, with greater improvement against what would be expected on key measures of health and health inequalities. GM shows that devolution can be successful, but also that it is hard work and will not happen as a matter of course. It relies on clear intent, consistency and coherence over time, underpinned by a strong vision and model for population health, and implemented and connected with economic goals at local authority level.

• This is a story of how change happens in a national policy context, when it is driven by a coherent vision and commitment at system and local authority level. It is a story that has lessons for a government seeking to deliver a health mission that is centred on closing regional gaps in health inequalities and for other systems seeking to improve population health.

Why did we do this work?

We know from a wide range of evidence that what is most important for a population’s health is action on the four pillars: the wider determinants of health (that is, the social, economic and environmental conditions in which we live, high‑quality and secure housing, a good job and a healthy environment); our health behaviours (whether we smoke, drink alcohol to excess, maintain a healthy diet and are physically active); and high-quality co-ordinated access to health and care services. All of these take place in the context of the fourth pillar: the communities we live in and the social relationships we have which help us stay resilient and to recover well from health problems.

A population health approach is one that recognises these four key pillars and the complexity of how they interact, and shifts resources and effort to where they will have the greatest impact.

In 2019, The King’s Fund was invited to help assess GM’s approach to population health and found it was in a strong position to capitalise on its work in preparing for, and in the immediate aftermath of, its devolution deal. Post-Covid-19 we were asked back to ‘hold up a mirror’ to the system and provide a reality check and assessment of how the population health system approach has developed since, with an emphasis on ‘the how’ – in particular, the critical role of GM’s local authorities, the relative roles and relationship between them and the regional bodies, and the impact of becoming an integrated care system (ICS).

Understanding how GM has developed its population health system approach offers many lessons for systems interested in improving population health and reducing health inequalities, as well as to national policy-makers about the levers required to support devolved systems to develop and progress population health system approaches in the context of the government’s health mission.

What did we do?

We reviewed a large range of published literature on the drivers of population health and existing studies of GM’s experience of devolution and health outcomes, as well as GM specific plans, strategies and other documents. In addition, between January 2023 and February 2024 we undertook three detailed case studies of the approach to population health in three metropolitan boroughs in GM (Bury, Stockport, Manchester) to understand in-depth how a population health system is understood and translated into practice at locality level. We also held two interactive workshops with senior leaders from across GM (from the statutory, and voluntary and community sectors) to develop and test our findings. In total, over 40 senior leaders participated in this research.

What did we find?

GM has been on its population health journey for a long time, and this is intimately connected to the wider devolution that GM has been party to. It has benefited from a clear and stable vision for population health that is well articulated, understood and supported at all levels of the system. It has held on to this through and beyond Covid-19, and through the evolution from the GM Health and Social Care Partnership to becoming the GM Integrated Care System. GM has invested time, effort and resources in increasing the capability to tackle health inequalities and to improve population health through strong analytical support, an academy model that invests in people and skills, strong networks (including its directors of population health), and in being open to external learning, evaluation and criticism.

This coherence supports, but does not constrain, approaches to population health in the constituent places and boroughs of GM. Our case study areas are very different in terms of demographics and wider context, but in each of them we saw: a strong coherence between economic and population health goals and plans; collaborative, cross-system working; clear governance, accountability and decision‑making at the right level; and an emphasis on working with communities.

However, GM’s journey has not been all plain sailing, and it isn’t over. It faces severe financial challenges as the health and care system and wider public sector reduces the bandwidth for long-term goals such as population health, and significant organisational change with the switch to becoming a formal ICS from the original health and social care partnership model. It has not been easy to keep making the case for population health and prevention, but it has been insistent and consistent in doing so, making the case with the aid of analytical capability and strong, coherent leadership. Perhaps the most important lesson for others is to have a clear vision, stay true to it and to keep learning. To turn back in the face of organisational change and financial pressures would be the wrong course.

What next?

The GM journey has implications for government policy on health and for the Department of Health and Social Care and other systems seeking to improve population health and narrow health inequalities.

The government needs to ensure that:

• its health mission is delivered through a population health approach that includes actions across the four ‘pillars’ of population health, not through the health and care system alone

• the health mission aligns with other missions and vice versa (to ensure, for example, that the economic growth mission does not inadvertently widen health inequalities in population health)

• sponsoring departments work coherently together below the national level, including through relationships with combined authorities and mayoral roles and other aspects of devolution as it develops in England.

The Department of Health and Social Care and NHS England need to:

• reiterate that population health is a core goal of ICSs

• ensure accountability systems and supporting tools are focused on population health goals

• design system levers that incentivise and reward action on population health

• resist the urge to reorganise system footprints, since long-term goals such as population health require constancy and stability.

Other ICSs and their partners pursuing population health approaches should:

• develop a widely owned vision and adopt a clear but flexible framework or model to help cohere efforts in service of it

• ensure clarity over system level and local roles and reflect this in governance

• constantly learn, develop and build capability for population health

• recognise that health and care system goals are dependent on wider action to improve population health

• work coherently to achieve population health and economic goals, as they are intertwined and co-dependent.