Aneurin Bevan said that ‘No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.’ This principle of universal access is the cornerstone of our NHS and long may it endure. But Greater Manchester’s devolution programme does pose a challenge to this principle and it is one of sufficiency. We have set ourselves the mission of the greatest and fastest possible improvement in the health of our population. The biggest barrier we face in achieving this goal is not access to medical treatment, important though that is, but rather tackling the corrosive impact of poverty and inequality.

On my office wall I have a map of the Greater Manchester tram network that shows the differences in life expectancy here. Within a matter of just a few stops and miles, we see a 10 year gap in average life-span that can only be explained by poverty and deprivation. We are not blind to this reality; it does not undermine the principle of universal access to recognise that some parts of our population need a deeper and wider offer, an offer that spans economic, social and clinical needs.

That is why when we took charge of the NHS in Greater Manchester we made clear that our intent was not principally the integration of health and care services, but rather to embark on a journey of much wider and deeper public service reform, that aligned as much as possible of the £22 billion we spend in Greater Manchester on public services to tackle the underlying barriers to greater health and wellbeing. This means that when we talk about integrated commissioning at local level there are no limits to a span that could potentially extend to housing, leisure services, welfare, community safety, etc. depending on local needs and preferences. And in establishing Local Care Organisations they could provide a wide range of services such as physical activity, occupational health and social welfare.

But even this extension is not enough. If the NHS in Greater Manchester is to achieve its objective of contributing to improvement in outcomes such as school readiness, numbers of people with disabilities in employment, reduced suicides, and reduced loneliness and isolation in later life, then we have to find ways of breaking the vicious cycle that traps people in poverty. People on low incomes pay more for food because they often don’t have access to cheap, healthy food and bulk discounts through supermarkets. They pay more for fuel because they are forced to use prepayment meters, and miss out on direct debit discounts. They pay more for finance because they can’t access mainstream credit and have to depend on doorstep lenders and other legal loan sharks. They pay more for furniture and household items, because they have to rely on rent-to-own companies rather than buying things outright.

Save the Children has estimated that this ‘Poverty Premium’ costs the average low-income household £1,300 per year. It contributes to debt, lack of affordable warmth, the ability to pay for essentials for themselves and their families, and to anxiety and depression. It means some young children going without toothpaste and toothbrushes so oral hygiene can’t be maintained. It means women unable to afford sanitary products. It means older people unable to keep their properties at a sensible temperature during the winter months.

This cycle and its consequences are unacceptable and not inevitable. There are solutions. Under health and care devolution we are already providing or developing some of them – health and work programmes to support people with health needs back into employment, a new oral health programme from birth to five-years-old to ensure low income families can help their kids get the best start in life, funding social workers in primary care practices in our most deprived neighbourhoods to work with families that are struggling. And there will be more to come.

But it isn’t just about what we can do directly. It is also about using our muscle to drive others to social action. It may mean lending our voice to the evidence to put pressure on other organisations to change the way they act, even when that is uncomfortable. It may mean promoting the use of social tariffs and other fairer pricing models, and finding ways to enhance access to goods and services that these households need to maintain good health. We can also use our commissioning powers to support the voluntary and community sector and social enterprises who want to provide alternatives for communities, such as bulk buying of essential goods, self-production and mutual aid schemes.

What this adds up to is helping people to help themselves through real choice and control. It is not about charity but rather about fairness and a more even platform. Get it right and the NHS will benefit in reduced demand. Ignore these wider determinants and our flotilla of vanguard programmes will be going nowhere in the force of the prevailing wind.

So as we strive for a new paradigm for our health and care system in Greater Manchester, we might expand Bevan’s statement, thus, “No society can legitimately call itself civilised if any person is denied the opportunity of good health or access to required medical aid because of lack of means.” This statement would truly reflect our mission as a National ‘Health’ Service.