Summary
This case study describes the work happening in Cheshire and Merseyside under the All Together Active programme which aims to increase levels of physical activity across the subregion by taking a whole system approach to tackle this ‘wicked issue’. Key successes to date in developing this whole system approach include:
- Developed a comprehensive All Together Active strategy for Cheshire and Merseyside in consultation with a wide breadth of stakeholders including locally trusted organisations to get the voice of the public.
- Developed a strong, wide-reaching network of people from 76 different organisations committed to improving physical activity in the subregion under the All Together Active governance structure.
- Secured commitment from system leaders including the Cheshire and Merseyside Health and Care Partnership whose recently refreshed strategy for 2024-29 calls for system-wide action to address the wider factors that influence health.
Cheshire and Merseyside will continue to build on this whole system approach, with a particular focus on using the Action Scales Model as well as embedding an evaluation framework to further understand impact and learning.
Increasingly in Public Health we are recognising that the challenges we are trying to address today are complex, multifactorial and cannot be solved by one organisation alone. Physical inactivity is an example of one of these complex problems. Widely recognised as one of the most effective interventions for improving and maintaining good physical and mental health, physical activity is often described as a ‘miracle pill’. But in an increasingly sedentary society, ensuring we optimise the benefits of moving more is becoming increasingly challenging.
In Cheshire and Merseyside (C&M) there are roughly 1m people that do not meet the minimum CMO guidelines for physical activity (Sport England Active Lives, 2024), with over 700,000 of these people doing less than 30 minutes of physical activity per week. Furthermore, inactivity is significantly higher in the more deprived areas of the subregion. In recognition of the high and inequitable physical inactivity rates, collective, system-wide action was required to make a real change.
The complex and adaptive nature of the C&M physical activity system was formally recognised in 2019 when the system came together to establish All Together Active. Initially a collaboration across the Integrated Care Board, C&M Active Partnerships, Champs Public Health Collaborative and local area physical activity leads, the sub-regional programme of work is using whole system approach methodology to create a collaborative approach to system level change. The programme of work started by mapping the causes of inactivity; this process formally recognised that despite movement being seen as free, easy and available there are many reasons why people are not moving more and being active.
The system mapping evidenced the complexity of the physical activity system in C&M. In response to this, partners have begun to use system thinking to respond to the complexity. This approach recognises that challenges are part of a wider system rather than a series of individual events. For example, increasing the number of children walking to school; taking a system thinking approach recognises the multiple factors that can influence this and how different parts of a system can enable this. Factors can include parents working hours giving them enough time to accompany young children on the journey to and from school, infrastructure to safely walk to and from school and the speed of traffic travelling along the walking route. Addressing all of these factors needs changes from across the system including from employers through flexible working policies, highways in making changes to neighbourhood infrastructure and potentially police enforcement of speed limits.
There has been real commitment to this system-level thinking to address the broader factors that influence our ability to live healthy, active lives. In 2022, C&M became a ‘Marmot Community’ following the publication of the landmark All Together Fairer report that was co-created by the Institute of Health Equity. Being a Marmot Community demonstrates C&M’s commitment to create greater health equity and narrow health inequalities through collective action on the social determinants of health, providing extra support to communities with the greatest need – principles which are core to the All Together Active programme. This strategic commitment was strengthened through the recent publication of the All Together Fairer: Our Health and Care Partnership Plan which calls for system-wide action to address the wider factors that influence health. Progress with tackling inequalities through All Together Fairer is measured through a set of Marmot Beacon Indicators, two of which focus on physical activity: activity level levels and active travel.
The work in C&M also recognises the need for system leadership and over the two years since the launch of the All Together Active Strategy the network of partners working on the programme has grown to 142. Two phases of consultation took place in order to develop and test the All Together Active strategy – 115 organisations from across the whole-system took part in the first phase, and 186 residents facing health inequalities reached through 17 locally trusted organisations took part in the second phase.
Next Steps
Over 130 partners attended a recent All Together Active conference to reflect on the learning over the past two years as well as thinking about how we continue to build our whole system approach with a particular focus on using the Action Scales Model. This approach will take the next step in beginning to embed the system beliefs and goals for physical activity, movement and sport across C&M as well as embedding an evaluation framework to understand impact and learning. The evaluation framework has been developed to focus on measuring system change, rather than a traditional approach of measuring outcomes, and we have the backing of health partners to take this approach as we know that population change will take time.
