Belfast

Belfast functional urban area (FUA) covers the city of Belfast itself and several smaller towns and rural areas, giving a combined total population of over half a million residents. However, local statistics which inform this report are based on the Belfast Local Government district which is somewhat smaller in geographic scope (population approx. 340,000).

Like all of Northern Ireland, Belfast is shaped by its history of sectarian division. Today, around half of the population identifies as Catholic (49%) and 42% as 'Protestant or other Christian' religion. It remains a city which is predominantly white (including Irish Travellers), with just under 4% from ethnic minority groups ^[ 1 ] .

The Northern Ireland conflict, also known as ‘The Troubles’, saw three decades of violent struggles resulting from ethno-national and ethno-religious divisions, ending with the Good Friday Agreement in 1998. This sectarian conflict ran from about 1968 to 1998 between the overwhelmingly Protestant unionists (loyalists), who wished to remain part of the United Kingdom, and the overwhelmingly Roman Catholic nationalists (republicans), who wanted Northern Ireland to (re)join the Republic of Ireland. During this time, Belfast was considered one of the most dangerous cities in the world, with a homicide rate of 30 per 100,000. There is still evidence of segregation and conflict across the city, with occasional tensions and the building of peace lines, with the most recent evidence being youth riots in March 2021.

As a result, the city is traditionally divided into four main areas which form the basis of constituencies for general elections: North Belfast, East Belfast, South Belfast, and West Belfast. These four areas meet at Belfast City Centre. These areas are subdivided, reflecting the religious geography and the divided nature of Northern Ireland as a whole. Walls known as ‘peace lines', originally erected by the British Army after August 1969, divide fourteen inner city neighbourhoods. Voting allegiance has been closely linked with religious identities; for instance, the Irish nationalist/republicans (mainly Roman Catholic) and unionist/loyalist (mainly Protestant). The city also bears the legacy of division in its housing, education and health systems in particular, but also across many publicly funded services and amenities.

In more recent years, Northern Ireland and Belfast in particular have gone through a dramatic process of transformation and reinvention. In particular, it has a booming television and film industry and has been the location for major national TV series as well as international hits like Game of Thrones being recorded in the wider region.

Today, Northern Ireland is the most equal part of the United Kingdom, which is a relatively unequal country when compared to other European countries. Using the 2017 Multiple Deprivation Measure, Belfast has the highest number of local government districts (LGDs) classified as among the "most deprived areas" in Northern Ireland in both overall numbers (50 areas) and as a proportion of all local areas (29%) ^[ 2 ] . The domains of the multiple deprivation measure are income, employment, education, skills and training, health and disability, access to services, living environment and crime.

There is an awareness of the level of inequalities within Belfast and addressing these is at the heart of the Belfast Agenda, which is the framework for priorities in the city. The Belfast Agenda is an innovative policy leading change and co-operation in Belfast. The Belfast Agenda is the city’s community plan, put together based on periods of consultation with key city partners and residents. The Belfast Agenda, set out by the City of Belfast in 2017 and written in collaboration with political parties, key community representatives, city partners and resident, is an innovative policy approach involving public consultations. It focuses on a shared vision to be achieved by 2035. Priority areas identified within the Belfast agenda are:

• To grow the economy
• To improve the quality of living experience in the city
• To develop the city in terms of transport infrastructure and transport
• To improve working and learning opportunities
• Become a city that offers inclusive growth for all communities.

As well as this, the City Council has put an Equality Acton plan in place to help put its value and vision in place, thus they have gone beyond statutory requirement to have specific disability, gender, LGBT and race workforce action plans ^[ 3 ] .

As of June 2020, 19% of the population is estimated to be children aged 0-15 years and 36% are aged 16-39 ^[ 4 ] . Population growth continues to lag behind national rates but the past decade has seen an increase in population size driven mostly by the increase in the young population.

In the UK, education policy is set by the four devolved nations (England, Scotland, Wales and Northern Ireland). In Northern Ireland, the structure of the education system in Northern Ireland is influenced by religion and dates back to the 19th century. Before 1921 and the partition of Ireland, almost all primary schools in Ireland, established from 1827 onwards, were denominational schools controlled by churches. During the 1920s and 1930s, Protestant churches gradually transferred control of their schools to the state, whilst Catholic churches continued to maintain control of their schools. Consequently, state schools became ‘controlled schools’ and the Catholic schools became ‘maintained schools’.

The 1989 Education Act introduced a new category of school: the integrated school. These schools bring children and staff together from both Catholic and Protestant traditions, as well as those of other faiths, or none. The aim is to ensure that children from diverse backgrounds are educated together and to cross traditional divides. The first integrated school was set up by a group of Catholic and Protestant parents in 1981. At present Northern Ireland has 65 integrated schools.

Today, children can receive a free education at controlled schools, Catholic schools, integrated schools and voluntary grammar schools (selective, based on educational attainment at age 11).

Northern Ireland has a reputation for producing academically high-achieving students. However, the gap in achievement between learners from advantaged and disadvantaged backgrounds continues to widen, with a significantly higher proportion of 17-24 year-old young people without any qualifications in comparison to other UK nations ^[ 5 ] . High achievers in Northern Ireland outperform the UK average, but underachievers fall far behind the UK average. Underachievement is closely linked to factors beyond the education system.

Regardless of religion and gender, students eligible for free school meals in Northern Ireland (based on low household income) have lower achievement levels than those who are not. Free school meal eligibility (FSME) is the most common indicator of social deprivation and disadvantage. In 2017/18, 32% of FSME pupils achieved 3+ GCSEs at grades A*-C including English and Maths, compared to 61% of non FSME pupils. In Belfast, 42% of young people entitled to free school meals achieve five GCSEs grade A* to C, including English and Maths, compared to 74 per cent of those who are not ^[ 6 ] .

There has also been a persistent gender achievement gap between boys and girls from 1963 to 2018. Nationally, girls are, on average, 16 percent more likely to achieve three or more GCSEs grades A*-C including English and Maths upon leaving school than boys ^[ 7 ] .

We also see an achievement gap between Catholic students, Protestant students, and students from other religious backgrounds. Catholics are on average 6.5 percent more likely to achieve three or more GCSEs grades A*-C including English and Maths upon leaving school than Protestant or Other pupils who do not identify as Catholic or Protestant over this time period ^[ 8 ] .

There is limited available data and/or research on different ethnic groups in Northern Ireland. However, the literature shows that minority ethnic and newcomer children are more likely to attend non-grammar secondary schools and hence represent a greater share of children within the integrated school sector ^[ 9 ] . Factors that represent barriers to accessing grammar education include a lack of knowledge of how the educational system works in Northern Ireland, as well as many grammar schools being specifically Catholic or Protestant. A high proportion of ethnic minority students leave school with no GCSEs; a further, more recent emerging inequality is that they were less likely to attain 2+ A Levels (Level 3 qualification) or 5+ GCSEs (including Maths and English at Level 2) than their white peers.

An intersectional approach reveals how different factors contribute to inequality in education. For example, combining three indicators of gender, religion and social background, in 2019/2020, 89.65% of Catholic Girls not FSME achieved at least 5 GCSEs(2) A*-C (including English and Maths) compared to just 46.7% of Protestant Boys who were FSME ^[ 9 ] .

All education policies are determined at a national level. Since devolution, one of the most important policies affecting education and education outcomes for the children of Northern Ireland has been the ‘Education Reform (NI) Order, 1989’. In addition to traditional subject areas, it means the curriculum offers a skills-based approach to personal development and contribution to society.

In 2021, the education minister of Northern Ireland tasked a panel of experts with creating an action plan to focus on improvement of educational achievement and chances, particularly for those from deprived backgrounds. The report of the panel, A Fair Start, recommends 47 actions to support educational achievement which will contribute towards tackling these inequalities. Recommendations include after school extracurricular activities, early years provision, focus on emotional and mental wellbeing and self-confidence and professional development for teachers ^[ 10 ] .

Another important policy linked to addressing gaps in educational outcomes is Every School a Good School ^[ 11 ] . This outlines priorities to support schools and teachers to raise standards and overcome barriers that some pupils may face. To achieve this, the policy focuses on six key areas: effective leadership for an ethos of aspiration; high quality teaching and learning; tackling barriers to learning; self-evaluation strategies at school level; bespoke support to schools; and a focus on improved communication between schools and parents. Promoting equality is also a policy priority, although detailed discussion exploring inequality factors is limited.

The ‘Extended Schools’ programme provided “wrap around services in schools”, such as care before and after school. This programme was seen by some as “an equalizer for people facing disadvantage” (local education expert interviewee) but this funding was withdrawn due to austerity measures post 2008.

The Community Relations, Equality and Diversity (CRED) in Education policy (2011) played an important role in “providing teachers and youth workers with the capacity to address what are often difficult and sensitive issues” ^[ 12 ] . This was, however, cut in 2014 due to austerity measures. The policy aim was to embed community relations, equality and diversity work impacting protected groups (persons of different religious belief, political opinion, race/ethnicity, age, marital status or sexual orientation; all genders; with disabilities; and with dependents) in the education system. A review of the policy found that it had been effective in embedding this work by providing resources and training to teachers, youth workers and schools, and that community relations were improving between students of different faiths and backgrounds.

The grammar school system is still an important aspect of the education model in Belfast; entry to grammar schools is less determined by area of residence and more by the 11+ entrance exams. The standardised national 11+ was formally abolished in 2010 thus entrance exams vary from school to school.

Changes in the demography and diversity of Belfast’s population, as well as increased pressure from grassroots organisations led by parents and educationalists, means there is more focus on educational reforms to tackle these inequalities. Raising standards so that all children, regardless of economic background, can succeed at school remains an area of focus.

At the local level, the Belfast Agenda is one of the policy interventions seeking to address these inequalities. An inter-agency group has been established with these partners: Education Authority, Department of Education, Belfast Area Partnership Boards, Queen’s University, Ulster University, Council for Catholic Maintained Schools, St Mary’s University College, Stranmillis University College, Urban Villages, Belfast City Council and Belfast Met. The partners have been using an evidence-based approach to identify best practice that can be used to improve educational outcomes.

An example of one joined up educational project is the ‘Youth Support Programme for 14-24 year olds’ which targets young people who are disengaged from employment or work and works closely with them to support skills development and GCSE revision programmes, so that they set their sights on aspirational careers. Support offered is tailored to the individual. Young people, teachers or even their carers apply directly to the programme and the team set up with the council will tailor support for them, by working with a list of mentors based around the city.

Other similar projects include a citywide GCSE revision programme, which supports 365 young people a year and an Easter School programme, which has supported 200+ students per year. These programmes specifically target and support inequality in education to raise achievement among the “long tail” of low achievement.

These programmes are reviewed as a wider review of the Belfast Agenda which is reviewed every four years. The most recent review found that past participants have raised their GCSE grades significantly and in some cases young people achieved A* grades. In 2019, for example, 86 per cent of those attending English classes and 65 per cent of those attending Maths achieved a grade C or higher. Sixty six per cent of participating students were entitled to Free School Meals, which, is an indication that the programme is supporting those in most need ^[ 13 ] .

Northern Ireland was traditionally an industrial economy, with Belfast being its major port, from the latter half of the mid-nineteenth century. However, in the early 20th Century, key sectors of linen and shipbuilding saw a gradual decline and economic transition and transformation was prolonged and difficult, due to the outbreak of civil unrest. Public sector roles became an important part of the economy, in line with other parts of the UK.

Northern Ireland was the UK region ‘hardest hit’ by the 2008 economic crash and subequent recession ^[ 14 ] . Typical household income fell by 8%, compared to 2% in other parts of the UK. Belfast’s status as the capital city of Northern Ireland meant that the reliance on the public sector acted as some form of a ‘cushion’ immediately after the period of the 2008 crash ^[ 15 ] . In 2007, the percentage of Belfast’s employees working in the public sector (35%) was higher than that in Northern Ireland (31%) and substantially higher than the average in the United Kingdom (23%) ^[ 16 ] . Nonetheless, the later austerity measures in response to the economic crisis did cause the public sector to shrink, which inevitably had a significant impact on the labour market in Belfast.

Despite economic growth before the 2008 crisis and again afterwards, unemployment has remained an issue in Belfast and is the second worst in Northern Ireland. Employment rates have improved slightly, rising from 64.3% in 2009 to 69.5% in 2019 ^[ 17 ] . As well as this, unemployment in Belfast is not evenly spread and neither was the economic resurgence that the city was experiencing in 2008.

There is a geographically unequal spread of economic growth and unemployment - often referred to as the “prisoners of geography” dilemma. Affordable and social housing is concentrated in areas of high deprivation such as Central Belfast, which are also areas where there is little opportunity for high quality employment. Job prospects are closely linked to transport links in the city. The city’s relatively high transportation costs and poor transportation network mean that many are locked-in to working near where they live ^[ 18 ] . As a result, central Belfast has seen vast unemployment, whilst wards around the city centre have seen rising employment opportunities. In 2017, the unemployment rate of Belfast city centre residents aged 16-24 was 19%, declining from 26% in 2009 ^[ 19 ] .

The Northern Ireland Economic Strategy (2012) was a result of the 2008 economic crash and included measures to boost and rebalance the economy ^[ 20 ] . It also acknowledged the impact the recession had on young people, such as limiting job opportunities. The strategy is structured in two streams: Rebuilding Themes and Rebalancing Themes.

Some of the Rebuilding Themes explicitly address inequality, such as a commitment to promote accessible employment opportunities in areas of economic disadvantage and offering training to those unemployed due to the crash, to address wider barriers to employment. Some of the more specific measures include a Social Investment Fund to tackle systemic issues such as deprivation and delivering 6000 work experience and training opportunities for young people by 2015 in priority sectors.

Some of the Rebalancing Themes indirectly target inequality, such as improving the skills of the workforce to ensure that people can progress, productivity can grow, and social inclusion can increase. This priority is also youth focused as many of the measures target the education system and school leaving options. For instance, measures include increasing skills in subject areas important to the NI economy such as STEM and increasing the proportion of young people leaving school having achieved at least 5 GCSEs at A*-C by 2020.

Another national programme was the Steps to Work Initiative. It was introduced in 2008 by the Department of Communities and designed to assist those unemployed/economically inactive to find and sustain employment. In Belfast, 31% of leavers from the program found employment and the most successful cohort of leavers of this program was youth aged 18-24 ^[ 21 ] .

Similarly, Pathways to Success targeted young people in the ‘Not in Education, Employment or Training’ (NEET) category and ran from 2012-2020. There was a combination of programmes which worked across multiple angles including skills building, family support, education support, and employment. The programme's holistic approach to unemployment was found to be an overall success ^[ 22 ] .

Other investment has come from international sources, particularly following the signing of the Good Friday Agreement when efforts were focused on rebuilding Northern Ireland. Notably, the region has benefited from substantial invesment via the European Social Fund (ESF) Investment for Growth & Jobs Programme.

Locally, there is a mismatch between the qualifications and skills that people have and the skills that are in demand in the labour force. The Belfast Agenda’s “Working and Learning” ambitions are focused on developing skills and qualifications, and educational attainment in the workforce, and decreasing the unemployment rate ^[ 23 ] . The aim is to address barriers to employment by delivering an integrated employability and skills approach, continuing the theme of using skills building to reduce inequality in employment.

According to the latest statement of progress, 5,855 jobs have been created, as well supporting 1,315 new business start-ups. The tourism sector has also evolved with investment secured to create further vacancies ^[ 24 ] .

The Belfast Employability and Skills Framework 2015-2025 builds on the Belfast Agenda and directly address some of the issues and concerns within the labour market, such as the impacts of generational worklessness and poor educational outcomes. One of its aims is “to increase access to employment by supporting the development of lower and entry level skills and by addressing barriers preventing access to jobs”. The intention is to achieve this by: increasing mobility to support access to employment; working with government partners to create better support to help economically inactive people back to work; creating a culture shift in aspirations of families with complex needs, create more opportunities for youth training; and providing up skilling and training to those furthest from the labour market.

The Local Development Plan (LDP) (2020-2035) Topic Paper: Employment and Economy focuses on tackling the high level of economic inactivity and deprivation in Belfast compared to the rest of NI ^[ 25 ] . One specific aim is to “tackle disadvantaged areas with high deprivation by ensuring access to local jobs”, addressing the “prisoner of geography” dilemma. However, the plan contains no precise policies or plans for how to achieve that aim.

Overall, there are concerted attempts and several policies and programmes to drive economic activity; employment opportunities are closely linked with the Belfast Agenda and are directing a culture of inclusive growth, aimed at benefitting the whole community. They are not, however, without their challenges and concerns exist among stakeholders about the long-term impacts of many programmes.

Housing in Belfast is still largely divided along old sectarian lines. Most residential areas are either predominantly (historically exclusively) occupied by Catholic or Protestant groups. Where these neighbourhoods meet ("interface areas"), there are often physical barriers separating them - high walls and fences to prevent violence, often including gates and closed roads to protect residents within. These were initially built during The Troubles but have in fact increased in number since the Good Friday Agreement and there remains over 21 miles of "Peace Lines" or "Peace Walls" in Belfast today. They are predominantly located in more deprived areas of the city and although some are now tourist attractions, as recently as 2017, many residents felt they remained an important part of peace-keeping in some areas ^[26] .

Plans were made to remove all Peace Lines by 2023 by "mutual consent". This is not set to be achieved but investment in local cross-community initiatives had led to the removal of nine of an estimated 97 interface structures by 2021.

The main piece of housing law in Northern Ireland is the Housing (Northern Ireland) Order 1981 (now on its 8th amendment). This order sets out the constitution, financing, and general functions of the Northern Ireland Housing Executive (NIHE) and relates to the formation, administration and registration of Housing Associations as well as overseeing any related acts.

The Northern Ireland Housing Executive was established in the 1960s to address housing issues and currently manages the Housing Selection Scheme which administers social housing. Social and affordable housing are separated by neighbourhood, which are separated by religion, so managing and administering housing support is complex.

Northern Ireland experienced a major housing boom in the early 2000s. The Northern Ireland housing market went from one of the most affordable in the UK to one of the least, and briefly it was only slightly more affordable than London ^[ 27 ] . The subsequent fall in house prices following the 2008 crash was far more severe than across the rest of the UK - between 2007 and 2015, there was a 51% drop in house prices. This returned the market to more traditional levels but left behind higher proportion of households in negative equity. Home ownership for first time buyers is also increasingly inaccessible because regulatory pressures have drastically reduced the availability of mortgage products for those with low or no deposits.

Segregated housing poses a huge problem for addressing housing inequality because social and affordable housing must be offered equally to both Protestants and Catholics and housing development also must be delivered equally. Segregation along religious and political lines, particularly in working class areas remains. One consequence is that if an individual or family are trying to access social housing, they would sometimes rather refuse a home in a particular neighbourhood and risk not being housed at all than take that home because they fear for their safety or they aren’t comfortable in that community. This also impacts homelessness and those that may require temporary housing.

The lack of affordability for home ownership combined with reduced funding for the social housing sector in recent years means that people on lower incomes have reduced housing choice. From 2011/12 to 2014/15, social housing financial investment fell by 31 percent ^[ 29 ] . The private rented sector in Northern Ireland has experienced experiential growth over the past 20 years and is now a similar size to the social rented sector ^[ 30 ] .

As well as affecting those on low incomes, it has particularly affected young people. This group is more reliant on social housing than any other population in Northern Ireland and 18-25 year olds make up 19.8% of people on the social housing list ^[ 31 ] .

The UK-wide welfare reforms also deepened inequalities in housing as they reduced affordability of housing. These reforms included the ‘Spare Room Subsidy Limits’, known as the ‘Bedroom Tax’, and the Benefit Cap, which limits the overall amount of welfare a household can claim.

Northern Ireland has policies and strategies aimed at addressing the housing crisis. One of the national policies that affects housing is the Strategic Planning Policy Statement (2015) which signalled the government intention for integrated housing. This policy focuses on mixed housing development to “facilitate an adequate and available supply of quality housing to meet the needs of everyone” ^[ 32 ] . One of the key strategies is “strengthen community cohesion”, which aims to offer a varied of housing types to meet a range of housing needs, whilst also ensuring opportunities for shared spaces, such as communal parks for children.

This theme of “strengthening community cohesion” is reiterated in the Regional Development Strategy (2012) which aims to “manage housing growth to achieve sustainable patterns of residential development”. This includes ensuring that all developments include social/intermediate housing and affordable housing so that the housing needs of residents are met ^[ 33 ] .

The Northern Ireland Housing Executive (NIHE) received £162m from the Social Housing Development Programme (SHDP) in 2021/22 – an increase of around £26m from 2022 ^[ 34 ] . As such, Northern Ireland devotes a higher proportion of its public expenditure to housing relative to the rest of the UK. 2,403 new social homes were started in Northern Ireland in 2020/21, 30% more than the 1,850 target set by the government. Despite this, Northern Ireland does not have a higher proportion of social housing (16%) when compared to the rest of the UK (e.g. 17% in England) and waiting lists continue to grow.

Planning policy is devolved to the local level in Northern Ireland and so the most pertinent opportunities for addressing housing inequality come at the city level in strategies such as The Belfast Local Development Plan. This is a 15 year framework which indirectly addresses housing inequality. It is being developed in consultation with the public and stakeholders to create a clear vision for how Belfast will look in terms of economic and social growth. One of the plan’s goals is to ensure that new developments offer a variety of house types, sizes, and tenures to meet a variety of housing needs. The plan goes on to outline plans for affordable housing, as well as specialized housing for example, housing for an older population showing a recognition of various housing needs and a plan to address them.

The Belfast Agenda also addresses housing inequality by committing to a goal of building 1,800 social housing units and a creating a city target for affordable housing. They also commit to working with the Northern Ireland Housing Executive to increase tenure mix and agree on a percentage of new homes that will be affordable housing. The Covid-19 pandemic, however, caused serious delays to construction.

In Northern Ireland, the National Health Service - which provides universal care, free at the point of delivery - was merged with the broader social care system in 1973 to form an integrated system called the Health and Social Care (HSC) system. The Northern Ireland government is responsible for organisational control and funding of the NHS systems, family planning, provision of health including services and public health ^[ 35 ] . Northern Ireland spends £2,3465 per head of population on health which is the highest of the four nations in the UK.

Mental illness is one of the major causes of ill health and disability in Northern Ireland which has 5% higher overall prevalence compared to England. One in five adults in NI has a mental health condition at any one time ^[ 36 ] . The persisting levels of deprivation and the traumatic legacy of Northern Ireland’s 30 years of social and political unrest are major contributors to this.

The Youth Wellbeing Prevalence Survey conducted in 2020 found a range of mental health problems amongst children and young people. 1 in 10 young people aged 11 – 19 years reported having engaged in self-injurious behaviour and roughly 1 in 8 reported have thought about or attempted suicide, with 6.6% having made a plan and 3.5% having made an attempt which is higher than the other nations in the UK ^[ 37 ] . Childhood experiences like poverty, addiction in families and intergenerational-trauma are linked to the emergence of mental health issues at a young age ^[38] .

Health inequalities persist for socio-economically disadvantaged groups. For example, men and women in the least deprived areas live 7.5 years and 4 years longer respectively than men and women who live in the most deprived areas. In the most deprived areas, 30% of people report a mental health problem - double the rate in least deprived areas; rates of suicide are also higher in more deprived areas ^[ 39 ] .

The Covid-19 pandemic has drawn further attention to the disparities in health outcomes for those living in deprived areas. The infection rate in the 10% most deprived areas was a fifth higher than the rate in the 10% least deprived areas. The hospital admission rate for Covid-19 (confirmed or suspected cases) in the 10% most deprived areas was almost double the rate in the 10% least deprived areas ^[ 40 ] .

The restrictions put in place to limit the spread of the virus also had "a severe impact" on children and young people, particularly those living in poverty. More than half (52%) of 16-year-olds who took part in one study felt their mental and emotional health had worsened during the pandemic ^[ 41 ] . Furthermore, the decline in play, recreational and leisure activities had a devastating impact on many children's physical health and mental wellbeing. However, problems with peers were substantially lower than other UK studies and rates of positive behaviours – such as giving, helping, and sharing – were higher.

Belfast itself has stark differences in life outcomes between people living only a few hundred yards apart within some parts of the city and there is evidence that outcomes begin to diverge even before birth. It has some of the highest quality health services in the UK and yet in 2012 had among the worst outcomes within sight of major teaching hospitals ^[ 42 ] .

Belfast contains the highest proportion of the most deprived areas of all local government districts in Northern Ireland. Male life expectancy is lower at birth, while drug related and alcohol specific mortality rates are higher in Belfast than across Northern Ireland ^[ 43 ] . Even within Belfast, in its most deprived areas, male life expectancy was 4.7 years less than the Belfast average and female life expectancy in the most deprived areas was 4.0 years less than the Belfast average. The largest gaps between the least and most deprived areas in Belfast are in drug related admission and death rates, self-harm admission rates, obesity and teenage birth rates for under 20s. Mirroring the national trend, suicide rates in the 10 per cent most deprived areas are almost five times higher than those in the 10 per cent least deprived ^[ 44 ] .

However, there has been an improvement in some indicators such as the gap between women from the most and least deprived areas who smoke during pregnancy ^[ 45 ] .

In 2011, a review of the provision of health and social care in Northern Ireland launched. The review noted that Northern Ireland was experiencing a growing and ageing population, deepening of health inequalities for the most deprived populations, and increased prevalence of long-term conditions such as hypertension, diabetes, obesity and asthma ^[ 46 ] . These factors, which inevitably lead to higher demand for health services, combined with workforce supply difficulties and greater pressure to deliver value for money, meant the health and social care system was deemed to be unsustainable without change.

In October 2016, a 10-year approach to transforming health and social care was launched - Health and Wellbeing 2026: Delivering Together - which is a person-centred care model focussed on prevention, early intervention, supporting independence and wellbeing, with care or support wherever possible provided in the community setting ^[ 47 ] .

However, progress was hampered by the lack of sufficient government funding to support this delivery model and meet rising pressures across hospital, GP practices, social care and mental health services, or to systematically tackle the growing waiting list backlog ^[ 48 ] . As a result, £100m of additional non–recurrent funding was allocated to the priority areas of elective care waiting lists, support services in primary care, workforce development, reform of hospital and community services, and capacity building in communities and prevention.

Within the Belfast Agenda is the ambition for everyone to experience good health and wellbeing. The ambition is that health inequalities will be reduced and those who suffer from poor health will receive the care and support they need. The Agenda includes a plan to invest £25 million in health improvement initiatives (in addition to investment in health and social care services in general) to make progress towards the ambition to reduce the life expectancy gap between the most and least deprived neighbourhoods. To achieve this ambition, the Belfast Strategic Partnership, will ensure the design and delivery of programmes that maximise the impact of the Making Life Better Strategy within Belfast.

The Belfast Strategic Partnership (BSP) was established by the Public Health Agency, Belfast City Council, and Belfast Health and Social Care Trust to provide a collaborative approach in addressing life inequalities in Belfast. The BSP is led by the three Chief Executive Officers and has representation from a wide range of organisations, including the community, statutory, voluntary and private sectors. The aim of the BSP is to champion and lead the case for tackling life inequalities across all communities in the Belfast area. It seeks to address aspects of physical health, including healthy eating, physical activity, active travel and mental wellbeing, particularly issues of social cohesion, community vulnerability and isolation.

The person-centred model of health care in Northern Ireland seeks to reduce spend on hospital services by shifting services out of hospitalised care and into primary care services, personal social services, and services provided in the community by the community & voluntary sector ^[ 49 ] . Youth Engagement Services and Active Belfast are some examples of specific policies to tackle health inequalities:

• Youth Engagement Services for children and young people is youth friendly, holistic health and well-being service. It caters for the health and improvement needs of children and young people aged 11-25 years old through the provision of information, education, singposting and, where appropriate, referral to specialist services. The range of needs includes: substance misuse, suicide and self-harm, mental health and wellbeing
• The Active Belfast project aims to promote healthy living and increase physical activity. A range of activities have been set up to encourage a healthier lifestyle: activities such as community gardens; cycling and walking routes have been set up to provide orienteering opportunities and eco trails; outdoor gyms throughout the city to provide access to a free fitness workout; there are also opportunities to get involved in sports activities.