Category Archives: Public Health

There have been bacteria on this planet for at least the last 3.5 billion years. For the entirety of our species’ existence we have relied on bacteria to aid us in breaking down food, whilst being helpless to guard against their wrath whenever we had a bacterial infection. It wasn’t until the late 19th century that more powerful microscopes lead us to understand what bacteria were and how the infections spread, in what was known at the time as ‘germ theory.’

Understanding how bacteria made people unwell led us to greatly improve hygiene; with large government programmes to build sanitation systems, doctors started to wash their hands and utensils, and people started to drink clean water. These changes, along with other medical innovation, lead to dramatic improvements in people’s health: in 1900 one in every 125 Americans were killed every year by infection and life expectancy was just 46; by 1941, it had risen to 65 and the number of people dying annually from infections had fallen to just one in 500. It was in this year that humans finally took the upper hand in our battle to stave of infection, when a research team in Oxford demonstrated how penicillin can cure bacterial infections. By 1955 just one in every 1670 Americans were killed by infections annually (the rate has plateaued since then).

Over the next few decades, antibiotics transformed modern medicine, not only allowing us to treat people who had bacterial infections, but also creating a safety net for other areas of medicine. Doctors can now treat other illnesses through surgery or by using drugs that have the unfortunate side effect of greatly lower immune systems (such as chemotherapy), with the knowledge that if someone picks up a bacterial infection, it can be treated.

Sadly, however, this was not the end of the story. Every time bacteria come into contact with antibiotics there is the possibility that through a process of natural selection, they may evolve to evade the drugs, creating what is referred to as ‘superbugs’. These superbugs can often not be killed by antibiotics. They have altered their membranes so the antibiotic cannot get into their cell, developed efflux pumps to remove the antibiotic from their system or learned to make enzymes that break down the antibiotic. In the early years of antibiotic development researchers were able to come up with enough new antibiotics to replace the ones that we had lost to resistance, but this is no longer the case. There has not been a new class of antibiotic able to treat gram-negative bacteria since the 1980s. This has led to a slowly-building crisis that kills 58,000 neonates in India every year and about 1.5 million people globally. If we do not start to take robust action against superbugs, then we are looking at returning to an era where bacteria are once again a major killer for which there is no cure.

In our recent book Superbugs: An Arms Race Against Bacteria,’ Will Hall, Jim O’Neill, and I look at the scientific, economic, and political failures that have led us to the point where antibiotics are ceasing to work, examine what will happen if we fail to act, before outlining the policy interventions that we think are required to keep us ahead in this vital arms race. In short, we need to new antibiotics to replace those lost to resistance; but more importantly we need to slow down the rise of resistance by preventing people from becoming sick, having better prescription practices when people become ill, and stop the environmental pollution from agriculture and manufacturing that sees antibiotics pumped into the environment.

All of these problems are held back by market failures. In order to prevent the rise of resistance, public health officials often rightly try to limit the sales of new antibiotics – the more valuable a drug the stronger the impulse to protect it is likely to be. This is problematic because innovators make greater returns the more of their product they sell though their patent system, which uses price and volume as a proxy for societal value. We need a new system for rewarding antibiotic producers that incentivise new drugs without encouraging companies to oversell.

Sanitation systems need to be improved in almost all low and many middle-income countries, so that people stop becoming sick. When we prevent illness then people will not need antibiotics. For example, at the moment, 1.7 million children die annually from diarrhoea or pneumonia, and research indicates that simply by getting people access to soap we could more than half this number. This is not just a problem in resource-constrained environments: in the US, research suggests that while 68% of people wash their hands after going to the toilet, only 5% did so thoroughly enough to remove all the bacteria on their hands.

Finally, with diagnostics and pollution we need to find ways of getting decision makers to internalise the societal benefits that accrue from good antibiotic stewardship. Regulation or taxation should be used to stop the environmental pollution of antibiotics. Rapid diagnostics can greatly improve prescriber practices, but there is a lack of investment into this area, and often when these diagnostics exist they end up costing more than the antibiotics, and so people do not use them. This means we are ignoring the societal benefit of using diagnostics to keep resistance at bay.

First published by the British Politics and Policy blog

Tagged | Leave a comment

In the year that celebrates the 70th anniversary of the ‘national treasure’ that is the National Health Service, this meeting of the Manchester Medical Society is more than timely. The origins of the NHS are rooted in the fight for social justice which runs not only in Manchester, Liverpool and the NorthWest but across the industrial and commercial north of the country. Next year here in Manchester, we will be commemorating the bi-centenary of the Peterloo Massacre in which 15 people, including one John Ashton, protesting about the poor social conditions and lack of suffrage, were slaughtered in a cavalry charge. This was a defining moment in the development of our democracy, the extension of suffrage and in due course to the extension of public services for the whole population.

On 5 July 1948, Aneurin Bevan, Minister of Health and midwife of the NHS inaugurated its first hospital, The Park, in Davyhulme in Trafford; and today, as we speak, former Health Minister and now elected Mayor of Greater Manchester, Andy Burnham is leading the charge for devolution and integration in partnership with the borough councils of this major conurbation. Along the M62 in Liverpool, William Henry Duncan, the country’s first full-time Medical Officer of Health pioneered a dynamic Victorian town hall based public health movement. His work has in recent years inspired a renaissance of public health going far beyond this region, a renaissance of importance when we come to looking at what the future holds in the next 70 years, not least with the long overdue move to devolution of government in arguably the most centralised country in Europe.

This talk will be in two parts. In the first, I will draw on my recent Lancet article of Nicholas Timmins’ formidable review of the first 70 years of the NHS to set the scene and identify some key challenges [1Ashton JRSeven decades of fighting the five giants: a work in progress. Lancet. 390 (10111): e47e48; 2017. DOI:10.1016/S0140-6736(17)32913-6[Crossref][Google Scholar]]. These challenges must be addressed if our grandchildren are to be able to benefit from the NHS and the Welfare State in their later years. In the second part, I will lay out my own conclusions based on a lifetime within the NHS and my experiences of trying to ensure that a balanced approach to prevention, treatment and care underpin the pursuit of social justice within a whole systems set of arrangements and characterised by visionary local leadership.

On 1 December 1942, queues stretched from his Majesty’s Stationery Office along High Holborn in London. By lunchtime all copies of Sir William Beveridge’s ground breaking report, Social Insurance and Allied Services  had been sold. It was much the same story elsewhere. In Liverpool, my father secured the two volume report that today takes pride of place in my study. Beveridge’s report sits alongside work by others who have guided me in my career: Brian Abel Smith, Douglas Black, Ann Cartwright, Karen Dunnell, Margot Jeffries, Jerry Morris, Richard Titmuss, Peter Townsend and many others associated with the London School of Economics and the London School of Hygiene and Tropical Medicine.

In the introduction to his report, Beveridge enunciated three principles that provided a framework for all that was to follow. First, in supporting the importance of learning from past experience, he spelled out that sectional interests (of doctors), should not be allowed to stand in the way of what was ‘a revolutionary moment in world history….a time for revolutions, not for patching’. Second, he was clear that social insurance – the focus of his terms of reference from Prime Minister Winston Churchill – was only one part of a comprehensive policy of social progress, before going on to declaim his most famous and Bunyonesque passage:

It is one part only of an attack upon five giant evils:

(1) upon the physical Want with which it is directly concerned
(2) upon Disease which often causes that Want and brings other troubles in its train
(3) upon Ignorance which no democracy can afford among its citizens
(4) upon Squalor …
(5) and upon Idleness which destroys wealth and corrupts men.

Finally, the principle of cooperation between the state and the individual was made explicit.

…..the state in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual…

Details of the Beveridge plan were broadcast throughout the day by the BBC in more than 20 languages. Copies of the report were dropped into France and circulated among the troops. Later, they were used by the Workers’ Educational Association in theatres of war as educational material that was subsequently held to have contributed to the election of the Labour government in 1945.

For many people, like my father, an insulin – dependent diabetic on low income with a growing family, the security offered by the prospects of comprehensive social security, including access to health care, was transformative. To academics at the London School of Economics and the London School of Hygiene and Tropical Medicine, the Beveridge Report was a bible for post-war reconstruction and an opportunity to put their intellectual muscle to work for the common good. They were to occupy an influential place in government policy – making that would last some 30 years before the Thatcherite revolution of the 1980s. The subsequent fashion for market – based solutions at all costs in the corridors of Whitehall swept away the consensus of solidarity that had emerged from pre-war hardships and the dark days of the fight against fascism in the Second World War.

By the time Nicholas Timmins published the first edition of The Five Giants: A Biography of the Welfare State [1995] that consensus was more than frayed at the edges after 11 years of Thatcherism and the rise of rampant free marketeers. As summed up by Julian le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics, the welfare state had been hit first by an ‘economic hurricane’ and later by ‘an ideological blizzard’. The demographic challenge was still to come. The ambition of the war-time generation to build a better future for their children was under attack in a cold climate. In returning to the fray with his new edition of ‘The Five Giants’, Timmins has taken on the monumental task of not only bringing his earlier work up to date but also of synthesising some 70 years of social policy in the UK, covering some of the most complex and interlocking areas that between them account for two-thirds of government expenditure.

Timmins describes his magnum opus as lying somewhere between ‘1066 and All That’ and Gibbon’s ‘Decline and Fall of the Roman Empire’. In agreeing with this assessment, I would add Salman Rushdie’s ‘Midnight’s Children’. Rushdie’s novel, in tackling the theme of India’s transition from British colonialism to independence through the use of magic realism, touches inadvertently on the surreal nature of many of the Shakespearean plots, subplots, and recurring themes to be found in ‘The Five Giants’. Through his device of a spiral treatment of health and social services, education, social security, housing and employment, Timmins provides a perceptive and comprehensive analysis of the British welfare state. I have long held that nobody should be allowed near the National Health Service who has not at least studied Richard Titmuss’ introductory lectures on social administration, written in the post-war period; to that essential bibliography, I would add this second edition by Nick Timmins.

Reading Timmins’ book I felt at times like a dying man with the whole of my life passing before me: hard times and rationing, mum counting every penny, national dried milk and welfare orange, the death of King George VI and the Coronation of Queen Elizabeth II, primary school in Liverpool with more than 40 children in a class in prefabricated huts, school milk and dinners, 6 weeks in Alder Hey Children’s Hospital with suspected meningitis, passing the 11+ examination while my brother failed it and was consigned to an underfunded and undervalued secondary modern school, constant interaction with the NHS for my dad’s diabetes, the discovery of the teenager during the Beatle years, and getting into medical school with a full grant. Then later as a doctor in the 1970s at the tail end of paternalism with ex-colonial administrators and later after the Griffiths Report of a new breed of general managers on huge salaries and flash cars, watching the slow descent of the UK into crisis followed by the rise of monetarism and oscillating nostrums that sapped the energy, without leading to sustainable change in the NHS.

This social history is all documented in Timmins’ truly remarkable book.

He chronicles the battles between different world views, veering between soap opera and epic, with ideology frequently trumping evidence; shallow rhetoric and narrow managerialism in place of authentic leadership, an increasing infatuation with keeping ministers happy in the Westminster bubble, a loss of focus on serving the people and being accountable to them, not least after the abolition of the Regional and District Health Authorities.

Nevertheless, at its heart the flame was kept alive, an enduring ambition to provide social security and freedom from fear for the whole population – for the many, not the few. Nick Timmins lays bare many of the underlying paradoxes, contradictions, and recurring challenges that underpin the muddling through so characteristic of UK Government social policy. He exposes the bankruptcy of politicians who seek short-term advantage at the expense of stability, progress and authentic leadership. Timmins’ blow-by-blow account of former Secretary of State for Health Andrew Lansley’s destructive and fragmentary NHS re-organisation, the orgasm of re-organisation heaped on re-organisation in an ever more frantic crescendo, captures the biggest threat to the NHS since 1948.

Years ago, in another life as a psychiatrist, I had as a patient a young man who was crippled with an obsessive compulsive disorder manifested by elaborate rituals. One day he told me that he had a plan to expunge his problem once and for all by acting out the ultimate in rituals in a local park. A few days later he returned to see me in great distress; he was half way through his ritual when he forgot what to do next. This image came into my mind most vividly at the height of Andrew Lansley’s structuralist madness.

Flawed Victorian notions such as ‘the undeserving and the deserving poor’, the principles of ‘lesser eligibility’ under which it was necessary to be completely destitute before receiving state help, and ‘the workhouse test’ make an unwelcome re-appearance in UK Government social policy dressed in new clothes (the virtual workhouse of Ken Loaches recent shocking film ‘I Daniel Blake’). In an age where we are functioning in a global economy, policies that will only reach part of the population prevent all citizens from reaching their full potential and put the national economy at a disadvantage.

The search for a unified system of tax and benefits continues. Centralisation proceeds apace dressed up as citizen empowerment. Thomas Gradgrind, Charles Dickens unfeeling character in ‘Hard Times is alive and well and living in the Treasury or the Department of Work and Pensions where knowing the price of everything and the value of nothing appears to be a prerequisite for promotion.

But not all politicians are bad guys. Tessa Jowell understood public health as Sarah Wollaston does today, but we are sadly lacking in the kind of leadership which is needed to take us forward to a new era that is fit for purpose. Timmins holds that George Godber and Liam Donaldson have been England’s best Chief Medical Officers. (I would add Donald Acheson) The civil servants in the Department of Health have often been dealt a poor hand in having to deal with contradictory political demands. Having worked closely with Duncan Nichol in our Mersey days I can attest to Duncan’s imagination and support for creative innovation and Simon Stevens is doing his best to unravel the mess that Lansley left behind. At the very beginning Churchill supported Beveridge, whilst the ambivalence of The British Medical Association was worthy of a contortionist.

And in the end many of the questions about how to provide population – based security out of general taxation remain, the ideological and the demographic. Of these, the demographic should be the most straight forward, and the Health Service must adapt to the needs of an increasingly elderly population – after all we have had over 30 years of knowing what was coming! The interdependence of the five giants is just as great today as it ever was. If we are to use our resources to optimal effect for the whole population, we need that interdependency to be understood by those charged with serving the public; we need citizens who understand it too. Timmins book provides a basis for that curriculum and is essential reading for all would-be public sector leaders.

In the second half of this talk, I will describe my conclusions about the agenda for such leaders that can carry us forward for the next 70 years.

So with Nick Timmins and ‘The Five Giants’ in mind we might ask ‘So what is the question that the constant tinkering is supposed to answer?’ The incessant reorganisation and obsession with structure to the detriment of function; the flirtations with privatisation and our fixation on the grossly unfair arrangements that are to be found in the USA where even the Health Maintenance Organisations such as Kaiser Permanente only cover employees; the constant threat of the introduction of regressive health insurance as an alternative to a system funded out of progressive taxation where there is pooling of risk. Meanwhile, we choose to ignore the experience of other countries, such as Finland, which have long since achieved the necessary transformational changes, within modest budgets, to put themselves on a sustainable path.

The starting point is how to optimise the health and well-being of the whole population, equitably, through a system of social security and welfare provision funded out of general taxation. It is daily apparent that essential services, services that make for a productive and healthy population [water and sanitation, energy, mass transit, education, housing and health] are too important to be left to the market, something that Richard Titmuss would have argued passionately 50 years ago. Ironically, we have been here before, as the recent demise of Carillion should remind us. Over 100 years ago the main utilities, including the gasworks and tramways were taken into municipal ownership, as later were coal mines, iron and steel and the railways because as essential services they could not survive without effective public interest oversight. In the fashionable dash to market-based purism that followed in recent decades, the public has become increasingly aware that the most obvious impact of privatisation has typically been the addition of around 10% to bills to satisfy the expectations of shareholders, without adding to the satisfaction of consumers. Health Services are no different, as the huge increase in transaction costs in the NHS over the past 30 years demonstrates. The distress of patients, workers and families that follows market failure from care homes to hospital construction is a price that the public is increasingly not prepared to pay. The burden imposed by the Private Finance Initiative is now seen for what it is: short sighted and obscene. Where were the voices of restraint at the seats of power when those decisions were being made? And those such as Alison Pollock who raised the alarm were ridiculed, vilified and disparaged.

If we ask why the NHS and similar systems in other countries arose in the first place, we find that an ethical impulse was often secondary to the imperatives of Empire and Industry, not to mention the actual survival of elites. In Germany, the ethical argument was made by Neumann in 1847 ‘The State argues that its responsibility is to protect people’s property rights. For most people the only property which they possess is their health; therefore the State has a responsibility to protect people’s health’. So much for the ‘Nanny State’. In fact, it was Bismarck, who, fearing revolution among the young men drawn into the cities by rapid urbanisation in 1848, the year of revolution in Europe, and fearing the spectre of the guillotine from France, implemented reforms in social welfare. In this country the extension of primary education in 1870 was motivated by the realisation that we were falling behind Germany and our European competitors. The consequence of finding that 40% of working class recruits to fight in South Africa in 1899–1902 were unfit for military service led to concerns about ‘how the country could maintain an Imperial Race and contain Germany’ and a comprehensive programme of action was proposed which included:

(1) A continuing anthropometric survey
(2) Registration of still births
(3) Studies of infant mortality
(4) Centres for maternal instruction
(5) Day nurseries
(6) Registration and supervision of working pregnant women
(7) Free school meals and medical inspection
(8) Physical training for children, training in hygiene and mother craft
(9) Prohibition of tobacco sales to children
(10) Education on the evils of drink
(11) Medical on entry to work
(12) Studies of the prevalence and effects of syphilis
(13) Extension of the Health Visiting Service

I don’t know about you but I am ashamed at the state of many of these essential public health services or their equivalent today, despite having had a National Public Health Agency now for six years. These late Victorian and Edwardian measures owe a great deal to Lloyd George who then built on them with his health insurance scheme in 1911, a scheme which resembles that of the American Health Maintenance Organisations which we seem to be so infatuated with despite them mostly being restricted to employees and their families. The great breakthrough with the NHS in 1948, three years after the death of Lloyd George’ was extending cover to the whole population, ‘equal access for equal need, free at the time of use and funded out of general taxation.’ The momentum that lay behind the consensus for the implementation of Beveridge was borne of shared hardship during the economic recession of the 1930s and in the Second World War fronts at home and abroad which transcended social class, although not the front between hospital medicine and general practice, private practice in London and medical practice in the rest of the country. In the event, it has been estimated that GPs doubled their pay in 1948 once bad debts had been taken into account. We have seen time and again how enduring is the public commitment to the NHS as a treasured national institution despite the fanatical determination of those on the political right for privatisation, returning time and time again like space invaders unwilling to learn from experience.

When the NHS was established in 1948, the public health picture was on the cusp of change. Infectious diseases, in particular those of childhood were in rapid decline as a result of improvements in living conditions, nutrition and the advent of comprehensive programmes of immunisation. Maternal and infant mortality rates were still high, certainly in comparison with today and life expectancy was a good deal shorter than now. The remarkable transition to a burden of disease characterised by non-communicable conditions and mental health problems was over 20 years away. However, the manifestations of unmet need were soon making an appearance, notably in relation to dental and optical care. As the pharmaceutical revolution proceeded along with a model of care dominated by hospitals, general practice was neglected and public health, temporarily consigned to the history books. In 1974, the arrangements that had placed the UK at the forefront of public health internationally, led by a Medical Officer of Health from the town hall were laid to rest, marking the high point of this chapter of hospital hegemony. Almost immediately, commentators began to argue the case for a renaissance of public health and for a reorientation of thinking, policy, organisation and practice. In 1976, Birmingham Social Medicine Professor Thomas Mckeown, demonstrated the fallacy that modern medicine had been responsible for the dramatic improvements in mortality rates over the previous 100 plus years; rather, most of the reduction in deaths from tuberculosis, bronchitis, pneumonia, whooping cough, and food and water-borne disease had already occurred before effective immunisation or treatment was available. Progress in these areas had probably had much more to do with smaller family size, improved environmental and housing conditions with advances in hygiene and the improved availability of cheap and safe food. Around the same time researchers such as Ann Cartwright, Peter Townsend and South Wales GP, Julian Tudor Hart began to point to the existence of an ‘Inverse Care Law’ in which the most highly trained doctors were to be found in the most privileged parts of the country and those with the worst health were least able to access high quality health care.

Tragically, over 40 years later and despite much hot air and lip service, we have failed to grasp the nettle, even when provided with the logical narrative and increased funding by Sir Derek Wanless. In 2004, Sir Derek persuaded the then Chancellor of the Exchequer, Gordon Brown to cough up significant extra funding for the NHS on the basis that it should be spent on resourcing a fundamental NHS reorientation to one of full public engagement and an upstream focus on prevention. In the event, the money disappeared into the Private Finance Initiative and a massive increase in clinical salaries. Every time dedicated funding has been identified for public health and prevention it has been diverted into balancing the hospital books. For me, the ‘Choosing Health’ monies, which I never saw, as Director of Public Health, was the epitome of the bad faith which emanated from Richmond House to be implemented at the local level. If I had a penny for every time I was told that we would get round to prevention once we had sorted out the hospitals I would be a rich man. And since the creation of Public Health England, another national body has failed to protect the frontline public health budget, standing by whilst the invidiously placed local authorities have diverted funding away from public health programmes such as family planning and sexual health to balance the books for social care.

Since McKeown published his analysis and others fleshed out our understanding of contemporary patterns of health and disease there has been no excuse for failure to transform our organised efforts and arrangements to optimise population health. This year we will celebrate 40 years of the AlmaAta Declaration made in Kazakhstan in 1978 and which underpinned the World Health Organisation Strategy of Health for all by the year 2000, adopted by the World Health Organisation in 1981. Health Services grounded in a whole population, whole system approach, the reorientation of health care towards primary and community care and upstream to prevention, tackling inequalities in health, full public engagement and partnership working and policies that support health within supportive environments; later this year in Alma Ata [now Almaty] these same principles will be revalidated. Finland is one of those countries that was listening when the Declaration was made. A Primary Care Act was passed which defined once and for all the proportion of capital spending to be dedicated to comprehensive primary and community health care. It included networks of modern community health beds, such as modern cottage hospitals linked to state of the art health centres across the country, a progression of high-quality community mental health facilities and general practitioners playing a key role at the front end of hospitals ensuring appropriate admissions. On a trip to the Finnish county of Karelia, with health service managers from Cumbria and Lancashire, where over 40 years ago Pekka Puska led a pioneering whole county approach to the prevention of coronary deaths, we heard of the systematic work that had skilled up the local population to manage common health conditions for themselves and resulted in a reduction in general practice consultations of between 20 and 30%; the Finnish Government itself was no hostage to commercial interests or allegations of ‘the nanny state’ and had been prepared to use the tools available to it in the form of legislation and taxation to create an environment that really did make ‘healthy choices the easy choices’. On that same trip to a country that in the early 1970s had had a notoriously bad diet, devoid of fresh fruit and vegetables, we visited a factory canteen where the workers were tucking in to an appetising selection of luncheon salads.

While this was going on in Finland and some other countries, in this country we were on a treadmill of structural reorganisation. In my 13 years as Regional Medical Officer, we underwent six – one every two years. Just as I had finished building up a team I had to start all over again. When I left the regional job in 2006 I commented that if I had wished to be a removals worker I would have joined Pickfords. I like to think that, together with colleagues here in the North West, we did make an impact in developing the New Public Health, not least in emulating what we could from Karelia with regard to heart disease and non-communicable disease in the absence of systematic government support; and certainly with teenage pregnancy and abortion, HIV and AIDS against central government opposition or apathy, but with the covert support of Chief Medical Officer, Sir Donald Acheson. How different it looks today with the present incumbents in Richmond House and Public Health England; a central team with little interest in public health and a lack of public health leadership in Public Health England, together with an unwillingness to challenge government, whilst neglecting the withering on the vine of local and regional public health since the transfer back to local authorities, now under the cosh of austerity and the centralisation of expertise and funding into a vanity project, a quasi-public health hospital in Harlow.

The Board of Public Health England is chaired by Sir Derek Myers, the former chief executive of Kensington borough council, where the disastrous Grenfell tower fire occurred last year, the Board itself having been recently recast as an advisory rather than an executive Board. In June last year the Guardian reported that Shelter Chairman Sir Derek and trustee Tony Rice had resigned because of concern over the organisation’s muted response to the Grenfell Tower fire. So what is needed to keep the faith with that noble generation that returned from war and with a bankrupt country delivered a National Health Service that the cynics and those with contrary vested interests said was impossible?

The manifesto to get us back on track and deliver equitable health and well-being to the population within affordable resources has five components which I will briefly outline:

(1) A clear vision. This vision is not rocket science and has been around since Thomas Mckeown and the Alma Ata Declaration 40 years ago. It is a vision of a whole system that tackles the 5 Giants, is rooted in public health and strong primary care which is a partnership with the population it serves. Community-Orientated Primary Care with its roots in Peckham in the 1930s, its adolescence in Johannesburg in the 1950s and a range of documented and persuasive experiments since, not least in Jerusalem, South Wales and Finland show the way. The integration of a whole population approach with the skills of epidemiology and public health alongside clinical and social care and a health literate public has to be the future, especially in the digital age. The combination of an anthropologically Place-based approach and Community Orientated Primary Care is a powerful one. The commercial determinants of health and disease must be confronted by both independent voices for public health and governments for whom the population’s health is more important than commercial interests.
(2) A convincing narrative. The failure of neither government nor managerial leadership to provide a convincing narrative of the future that we need is a disgrace. Much of it has been implicit but the repeated reorganisations and ill thought through dalliance with the private sector has happened because of the failure to describe the future and take people on a transformational journey. When Sir Derek Wanless published his report I managed to get a personal submission into Prime Minister Blair’s Christmas red box which brought together much of the argument presented in this talk and urged him to take a different path. The complacency of his reply shocked me and we have all lived through what has happened subsequently. In particular, I had suggested that he make use of his Directors of Public Health to argue the logical case for change in order to give the politicians the evidence-based justification to see it through. If anything today Directors of Public Health have been even more marginalised when they could be important allies.
(3) Authentic leadership. When Sir Roy Griffiths suggested that Florence Nightingale would be hard pressed to find a satisfactory answer to the question of who was in charge of our hospitals in 1983, the answer was seen to lie with general management. 35 years later it has failed to deliver. Too often, very highly, not to say excessively paid NHS chief executives have failed to provide either leadership or delivery to their communities and have failed to take responsibility when things have gone wrong, often finishing up with national honours en route. In part, their recruitment and training is to blame, and the move to greater clinical management is to be welcomed, but we are still producing chief executives and finance directors who are trained in silos with a narrow range of skills when it would be better for them to be trained in regional multi-agency staff colleges that included future leaders from all the health and social care professions, public health, the voluntary sector, the police, the media, academia and political life to list a few. That there can be chief executives from a range of backgrounds including finance who are unable to make sense of health outcome data or be on top of safeguarding and clinical risk management is unacceptable. As Director of Public Health I battled without success over many years to have health items and health data given the same prominence on Monday morning top team agendas as finance data.
(4) Full public engagement. The medical model of health services that was inherited from the private sector is not fit for purpose. As George Bernard Shaw put it ‘All professions are conspiracies against the laity’ and medicine is no exception. The nature of a profession is that of putting up one’s plate in the high street and seeing those customers who can afford to pay. It is not fundamentally about either a population focus with equity at its heart or empowerment but is about giving away small pieces of expertise in exchange for payment, not wishing to take the bread from its own mouth. The result is the creation of dependency and inappropriate demand that is not in the public interest and results in the deskilling of the workforce. This applies in the relationship between primary and secondary care where innovation of intervention and expertise has tended to remain hospital bound long after it could have been disseminated. Compare the situation with the motor car industry where expensive expertise is to be found in research and development followed by large scale, high quality and economic delivery. We have begun to realise that such a model can apply to long term conditions as well as to surgery. The modern equivalent of the Home Medical Encyclopedia, which my parents depended on before the NHS, is the internet backed up by proper school education in the classroom, by the full range of accessible allied health professionals and by peer led expert patient groups. In public health, there is now mainstream interest in Asset Based Community Development in which individuals and communities are seen as being half full rather than half empty dependent always on professionals coming along to fix them in a state of childlike dependency. It’s time the NHS and its leaders cottoned on.
(5) Adequate resources. Resources in the sense of money are usually the first item to be discussed in relation to the National Health Service. However, the way we frame the questions at the moment there can never be enough money. If we turn things on their head and build a system built on healthy public policies, full citizen engagement and a public health grounded clinical system money is the final question and it is about what it takes to make the system work. In a sense Simon Stevens has been trying to pursue this approach with the five Year Forward View, the programme of Vanguards (incidentally a Trotskyist notion of the leaders having all the answers), and the Sustainability and Transformation Plans which whilst well-meaning have slipped into the Richmond House default position of top down planning in nowadays smoke free, darkened rooms.

These five major components of the change we need must be backed up by a proper population evidence base, appropriate capacity and capability, and arrangements, curriculae and institutions that are fit for purpose. In turn, this has significant implications for our understanding of the values and cultures of a wide range of professional groups, their ability to work collegiately across agencies and as equals with members of the public. It would help if politicians had proper induction into the issues along with the officers who they must work with and if there was clear water between the public and private services and self-interest. But the most important element is co-productive, ethical and challenging leadership at all levels and across the whole system.

Here, in Manchester and in the North generally where there is increasing anger at the failure of our centralised national system of government to deliver, not only on the NHS but with tackling all five Giants and beyond Devolution can bring hope. Andy Burnham and Steve Rotherham, the great cities and counties working together as Leaders of Place can use soft and convening power with an outward focus to transform life for millions. They can push the boundaries free from the fossilised processes that hold us back and provide accountable voices for local people; early examples of the momentum for change that is building include homelessness, environmental sustainability, the need for a living wage and the obscenity of very high pay and inequality. Mayor Bloomberg in New York has given us a flavour of the potential of an elected mayor in championing public health and I have personally witnessed the power and influence of 1000 such first citizens committing themselves in cities across Latin America.

I have had the privilege of working with the World Health Organisation Healthy Cities initiative, which now involves over 1400 cities worldwide, for the past 32 years. Next month  February 2018) in Copenhagen there will be a summit of elected city and metropolitan mayors from around the world marking a new phase of political leadership at the city level. The focus will be on six P’s:People, Place and Participation; Peace, Prosperity and the Planet. Beveridge’s five Giants are now a global threat; by working together not just here in Manchester but in concert around the world we can keep the faith with those who gave us the NHS on 5th July 1948.

This was the Telford Memorial Lecture at Manchester Medical Society – 31st January 2018.

Tagged , | 2 Comments

On 15 April 2018 Doctors of the World (DOTW) and the National AIDS Trust (NAT) issued a joint statement that called on NHS Digital to immediately stop sharing patient details with Home Office immigration authorities.

DOTW and NAT believe that sharing confidential patient information with the Home Office will deter vulnerable migrant groups from seeking antenatal care or urgent care for infectious diseases.

Here is the DOTW statement:

MPs repeat demand for an end to NHS Digital sharing patient data

The House of Commons Health & Social Care Committee has, for a second time, called on NHS Digital to immediately stop sharing patient details with the immigration authorities. Expressing deep concern about the Government’s approach to sharing confidential patient information, a report released by the Committee on 15 April stated: ‘we believe that patients’ addresses, collected for the purposes of health and social care, should continue to be regarded as confidential.’

The report also states the Committee’s lack of confidence in the leadership of NHS Digital, citing the failure of NHS Digital to act independently of Government and its disregard for the underlying ethical implications of this data-sharing.

Currently, the Home Office receives information about patients from NHS Digital, the body charged with safeguarding patient data. The data is used to trace migrants, which creates a climate of fear where vulnerable people – including pregnant women and those who have been trafficked – are too afraid to access healthcare.

DOTW (Doctors of the World) UK and NAT (National AIDS Trust) have been campaigning for an end to this practice since it came to light in 2014. Both charities gave evidence in the Health & Social Care Committee’s initial hearing on the issue.

Lucy Jones, Director of Programmes at DOTW, said: “In our clinic, day in day out, we see the incredibly harmful impact the data-sharing deal has on our patients. It has reached a point where people do not want to give the NHS their contact information out of pure fear. While confidentiality is in such a precarious state, mothers are not accessing the antenatal care they need, public health is put at risk, and we fear this is only going to get worse”.

“Doctors of the World UK stand with the Health Select and Social Care Committee in opposing this dangerous information-sharing deal between NHS Digital and the Home Office, and are thrilled the Committee has taken such a strong stance. This view is also shared by the British Medical Association[1] and the Royal College of GPs[2]. As a healthcare charity, we believe in the right to healthcare for all. Yet this immoral deal works to scare some of the most vulnerable people in society from seeing a doctor.”

Deborah Gold, Chief Executive of NAT said: “It is scandalous that our data is being shared and our privacy corroded with less and less justification. As an HIV charity, we understand the importance of treating infectious conditions and limiting the spread of epidemics. When people can’t trust the NHS with their data, that good work is undone and we face a public health risk. There is nothing to be said for this practice, which deters people from accessing healthcare.

“Data sharing should have been stopped when the Health & Social Care Committee first called for it, and it certainly should stop now they have, for a second time, demanded an end to this short-sighted and unethical practice.”

Sign our #StopSharing petition to support our NHS Doctors and tell NHS Digital they are NOT Border Guards:

https://www.doctorsoftheworld.org.uk/stopsharing-campaign

[1]https://www.bma.org.uk/news/2018/january/patient-information-shared-with-immigration-officials

[2]http://www.rcgp.org.uk/-/media/Files/News/2018/RCGP-letter-to-NHS-digital-from-chair-march-2018.ashx?la=en

The Commons Health Select Committee says:

Dr Sarah Wollaston MP (Chair): NHS Digital are an organisation that the public need to have absolute confidence will respect and understand the ethical principles behind data-sharing [and they] have not shown us at all that this is part of what [they] are considering’.

Dr Paul Williams, MP for Stockton South and a practicing GP, questioned “what advice would you give to clinicians about what they should inform their patients so that this information is classed “with consent”?’

Luciana Berger, the MP for Liverpool, Wavertree urged NHS Digital to reconsider, calling the deal ‘a matter of life and death’ for an extremely marginalised and vulnerable patient group. 

Tagged | Leave a comment

This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

Leave a comment
SRH sector join forces and call on SoS Jeremy Hunt to strengthen local authorities’ SRH mandate

Key SRH and public health stakeholders such as FSRH, BASHH, BHIVA, FPH, NAT, THT, FPA and Brook have sent an open letter to Secretary of State Jeremy Hunt highlighting the challenges currently faced by the sector.

The open letter puts forward a set of recommendations, including fully-funded SRH services based on the needs of the population; delivery of SRH services by local authorities in accordance with nationally recognised standards such as FSRH, BASHH and the new BHIVA standards; enhanced accountability mechanisms, among others.

The letter comes in the footsteps of a call for evidence launched by the Department of Health and Social Care (DHSC) on the impact of local authority public health prescribed activity. It is now over four years since public health duties transferred back to local authorities, and the Government wants to take stock of the regulations to consider whether the current arrangements set out in the 2013 regulations will, in the future, be fit for purpose. This is given added relevance by the announcement in December 2017 that the Government intends to replace the ring-fenced public health grant with local authorities’ own business rates retention funding from 2020.

You can read the following letter in full here on the FSRH website:

The Rt Hon Jeremy Hunt MP
Secretary of State
39 Victoria Street
London
United Kingdom
SW1H 0EU

18th April 2018

Dear Secretary of State,

Sexual and reproductive health sector call to strengthen the public health framework

The sexual and reproductive health (SRH) sector strongly welcomes the Government’s call for evidence on the impacts of the current prescribing regulations for local authority public health activity. This is a much-needed stock-take of the existing framework following the radical changes resulting from the 2012 Health and Social Care Act which transferred public health responsibilities from the NHS to local authorities.

We represent hundreds of thousands of healthcare professionals who work within the current public health framework as well as service users and the general population whose needs must be considered first and foremost in public health policy.

The implementation of the existing public health framework has brought challenges, and these have undoubtedly been exacerbated by significant cuts to the public health grant. Financial pressures have impacted on local authorities’ ability to even maintain the current levels of service provision, and evidence points out that budget reductions are leading to unacceptable variation in the quality and quantity of services available to the public.

Strengthening the SRH mandate by enhancing the scope of prescribed activity and accountability mechanisms is vital to ensuring that key services are consistently provided across the country. However, much remains to be done to tackle regional inequalities. Cuts, coupled with fragmented commissioning, have had a severe impact on access to contraception, including emergency contraception. They are also undermining the delivery of effective sexually transmitted infection (STI) prevention, testing and treatment services, which is especially concerning considering the recent explosion in syphilis rates and the continued spread of antibiotic-resistant gonorrhoea. The significant pressures caused by the cuts are limiting patient access to SRH services across the country and are ultimately jeopardising health outcomes as a result.

Non-prescribed public health activities have faced significant service cuts too (for example, HIV prevention funding in areas of high prevalence dropped by a third in two years). This strongly suggests that any potential removal of the public health grant ring-fence will inevitably lead to further redistribution of funds to other equally-as-pressured parts of the system. We are also concerned that the proposal to fund public health through locally retained business rates in 2020 could compound health inequalities in socio-economically deprived areas. With increasing uncertainty surrounding local authority financing, it is vital that the public health framework is strengthened to ensure that SRH services are truly open-access and available to all, so that health inequalities are not deepened.

We would therefore like to bring to DHSC’s attention a common set of recommendations agreed on by the SRH sector which are important to strengthen the effectiveness of the SRH mandate:

1. That sexual and reproductive healthcare services are fully-funded based on the needs of the population.

2. SRH services must be delivered by local authorities in accordance with nationally recognised standards in SRH, such as FSRH, BASHH and the new BHIVA standards, guaranteeing high-quality SRH care. These standards should be expressly referred to in the mandate to protect services from being compromised by cuts to budgets and politicisation at local authority level. We would particularly like to see DHSC and PHE collaborate on strengthening the SRH mandate for use at the local authority level.

3. For tools to be developed to support local authorities to assess the impact of their prescribed activities on health inequalities, such as inequality impact assessments.

4. DHSC to ensure that joint working happens in practice, supporting local authorities and Clinical Commissioning Groups with their SRH commissioning responsibilities in line with the collaborative and whole-system approach to commissioning outlined in PHE’s ‘Making it work: a guide to whole system commissioning for sexual health, reproductive health and HIV’.

5. Given the APPG for Sexual & Reproductive Health’s Inquiry findings that there is a lack of clarity with regards to accountability in the current system, that existing accountability mechanisms are enhanced, enabling the Secretary of State to hold local authorities to account in their devolved delivery of his public health responsibilities.

6. That PHE has stronger enforcement powers to enable the agency to act on the findings and analyses it produces and to hold local authorities and commissioners to account for their performance.

7. Accountability lines must be further developed if the business rates retention system is introduced in 2020, with further consultation in this regard.

We are clear that changes are needed to make the public health regulations work now, and to ensure that they are fit for the future. We urge the Government to consult further on specific changes and to do so in the context of clear proposals for how public health responsibilities will be funded in the future. It is essential that the sector has further opportunity to scrutinise the framework in this context.

Finally, we strongly encourage the Department to take fully into account the detailed recommendations set forth in our individual responses.

Yours sincerely,

Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists (FSRH)
National AIDS Trust (NAT)
British HIV Association (BHIVA)
Brook
Family Planning Association (FPA)
British Association for Sexual Health and HIV (BASHH)
Terrence Higgins Trust (THT)
Faculty of Public Health (FPH)

Leave a comment

It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.

Smoking

Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

Obesity and malnutrition

I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

NHS funding

Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

Tagged | Leave a comment

This is the second in a series. The first blog set out some background, context, language and framing issues. Here I set out some thoughts on intervention. Again, it’s a little fiddly.

  1. General principles & Framework

There are a number of different evidence based approaches to what we can do, such as those produced by Marmot, Due North or our own Strategy, to name just three. This needs to be put into a framework, and a decision made regarding how to focus.  See blog 1 for some thoughts.

For example a framework could develop around behaviour, determinants, communities, health and social care.  It could also be framed around the life course (starting well, living well, ageing well), or in terms of services for people and places where people live.  Any serious effort to address health inequalities must start with inequalities in outcomes around employment, income and housing and wealth inequality/ownership of capital.

There are a number of recurrent themes in a discussion  on general principles:

  • Resist single silver bullet answers: all domains need answers and solutions. Everyone wants pithy answers: they don’t exist.  Marmot’s recipe still stands and hasn’t been beaten.  There isn’t a single intervention – policy or service wise – that will crack this issue;
  • Most are unconvinced that “writing plans” will solve or make much progress. As above, measurement is easy, and talk is easy, but concrete progress is difficult.  Whilst we probably don’t need to measure progress on indicators with ever finer grain detail, we DO need to ensure that implementation of interventions is robustly monitored.  There is something to consider regarding the underlying narrative and whether we really believe it, also something around an organising principle to be hardwired into organisational DNA rather than a standalone plan (while accepting someone somewhere might occasionally need to do something);
  • Complex system: one of the things that has hindered progress is the size and complexity of the issue. Progress may depend on the interplay of national and local government policy, with aspirational and practical actions for local players.  In addition outcomes are a complex interplay of health; wealth; education; poverty; family etc.  All interact in ways we often don’t fully understand but all matter, and can’t really be adequately addressed in silos.  This is compounded by the fact that progress in this area is NOT the path of least resistance, especially at times of shrinking budgets;
  • Influence by proposition: splitting the agenda into actionable chunks might help but not letting sight of the whole is equally important. Health inequalities are cross cutting not “owned”.  We need to think how to frame cross cutting issues in ways that have traction across and within silos.  This leads to questions such as: What and who do we want to influence?  What do we want in terms of resource, power, and permission?
  1. PHE guidance is helpful. System, scale, sustained effort.

Consider those areas that have seen real change. It’s mostly a combination of doing  different stuff better (transformation) or / and sustained effort to do the right things, at scale, over a long time (aggregation of marginal gains).

Recently PHE guidance – reducing health inequalities: system, scale and sustainability – set out a revision of the DH Health Inequalities National Support team work

Key points:

  • intervening at different levels of risk – phsysiological (BP, cholesterol), behavioural (smoking), psychosocial. All interconnect. All need attention. Don’t neglect one at the expense of others
  • intervening for impact over time
  • intervening across the life course – start well, live well, age well. Direct link to Marmot themes.
  • to have real impact at population level, interventions need to be sustainable and systematically delivered at a scale in order to reach large sections of the population. Reach and coverage of effective high impact interventions in populations.
  • In medical terms most of the gap is made up of CVD, respiratory, Cancer – thus think of prevention in the context of risks for those broad areas,

 Not just service level

  • Intervening at civic, community and service levels can separately impact on population health. In combination, the impact will be greater.
    • Civic interventions – through healthy public policy, including legislation, taxation, welfare and campaigns can mitigate against the structural obstacles to good health. Adopting a Health in All Policies approach can support local authorities to embed action on health inequalities across their wide ranging functions.
    • At a community level, encouraging communities to be more self-managing and to take control of factors affecting their health and wellbeing is beneficial. It is useful to build capacity by involving people as community champions, peer support or similar. This can develop strong collaborative/partnership relationships that in turn support good health.
  1. Specifics
  2. General

Multiple authors and commissions have published many detailed specific and generic recommendations and policy prescriptions.  Each prescription has merit and there is some overlap between different publications, while many of the recommendations are of relevance to national agencies, some to regional agencies, and some to local agencies.  Some of the national recommendations may be localisable (either directly or through devolution).

Some interventions are within SCC control, some are within the city’s control and some are NOT within immediate control.  We should consider “the ask” of our services and policy areas, and what cuts across many services or portfolios.

A simple prescription is not possible, but the following themes are commonly cited:

  • Differential resourcing: this is the disproportionate distribution of resources, services and assets to meet disproportionate need (and inequitable outcomes). It is unknown whether the distribution of resources (wrapped into service delivery or otherwise) and assets reflects the patterns of need.  In NHS delivery there IS a mismatch, and the challenge is to disproportionately invest in a generalist offer matched to need levels.  We don’t know the extent to which this story is reflected across sectors within the economy.

This may not ONLY be a debate about “resources” defined narrowly or broadly, but also about the right policy framework and coverage of effective interventions.  In a net zero new cash environment, there may be merit in exploring mechanisms for addressing resource inequity: hold top and level up vs level down vs some other version of how the principle is operationalised.  Whatever mechanisms are used the need is to focus the greatest resources where need is highest, and not disinvest as it is more expensive improving outcomes in the populations with most need;

  • Re-look at the economic impact of inequality: GVA vs broader social benefits. Inclusive growth vs sustainable economy.  Addressing inequality is NECESSARY for economic growth.  There will be merit in relooking at the public sector supply chain in this and how well we really enact social value in our commissioning, inclusive growth & sustainable economy, living wage and our role as employer around skills and jobs.  In this area the wealth gap is (by far) the most important, however not easily or quickly resolvable.  This obviously lends itself to the narrative on inclusive growth, and that may be a more effective line to pursue;
  • Community capacity and power: some call this “community development”. Some have suggested that the various strategies for community capacity building (PKW, Neighbourhoods and others) are too small, marginal, insecurely funded and not well enough connected.  There may be merit in relooking at how we commission volcom organisations, and what our expectations are of them both in terms of service delivery and in terms of voice and capacity development.  Linked to this, but not just in this domain, is the focus on a needs (the needs of the marginalised) vs assets (scope of opportunity) approach and a greater sense of coherence across areas.  Some of the key issues here are financial insecurity, anxiety about not being in control of where they live (‘social cohesion’) and a cynicism about local services.  Our strategies are a mixture of responding to crisis and jam tomorrow (employment); we often miss out the bit in the middle: addressing current insecurities and vulnerabilities;
  • Inequality and poverty are obviously inextricably linked and might be viewed as different lenses on broadly the same issues. All of absolute poverty (not having money makes a difference), relative poverty (the size of the gap between best and worst) and the floor threshold (mustn’t fall below) are important.  On relative measures, we need to compare mean and median income for instance, as both measures can tell different stories;
  • There is a clear case for investment in debt advice, cheap credit & welfare rights for those most financially vulnerable, in the context of welfare reform. The welfare budget dwarfs the NHS (£215 billion spent in 2015/16 on social welfare support including pensions, or £125 billion on means tested and disability benefits); it IS a determinant of health and is likely differentially affecting the most vulnerable.  Relatively little effort is put to understanding need in this space; for example, the level of problematic debt among key populations.  The tax and benefit system is certainly affecting child poverty and living standards have got worse for families with kids.  Recent IFS figures projected that the 2015 budget will mean the income for families with children will get worse at a level proportionate with starting income, i.e.  it is regressive making the lot of the worst off worse;
  • Participation in education and generating aspiration is important. Investment in children’s outcomes is a long term infrastructure investment for economic prosperity.  “That’s not for kids from round here”.  Kids often have high ambitions until they are 13 or so, then those ambitions are dulled.  The job is keeping them with high ambition through to career.  The opposite is to deliberately create the equivalent of “pushy parents”.  Demanding, wanting the best, articulate a different vision of the future.  Hunger for learning that drives self-esteem and attainment.  There may also be a case to reconsider the pathways into work especially those looked after, care leavers, no qualifications, learning disabled.  The role of multi academy trusts needs consideration.  Some will get this agenda, some may not.  See here – for an example of capacity development across a large number of schools.
  1. Evidence base. Health inequalities evidence based policy prescriptions and interventions. What to do?

 This section presents a summary based on available sources of evidence – ie it is evidence led, rather than idea led.

There is no shortage of policy prescriptions and ideas. This document isn’t necessarily complete, many will find glaring holes, thus should be viewed as work in progres

  • Effort make to ensure ideas are positive not patronising, life course focused, and focus on structural interventions
  • Effort made here to focus on issues with local traction, some national ideas included – become targets for advocacy.
  • Interventions need to focus on services for people, places where people live and structural policy interventions.

Considerations in evidence led approaches

One overarching issue common to all the evidence reviews is that upstream policy measures to reduce material poverty and deprivation are crucial to prevent extreme social and health inequalities from occurring in the first place, this fact is often overlooked in the “evidence base”, thus evidence around “poverty” is equally as important as evidence around “health inequality”

How this evidence is interpreted depends on whether a social or medical model of health is taken (arguably both are relevant); and the timeframe in which results are expected.

Marmot

Marmot 2013 remains the most valid and comprehensive guide

Reminder of key messages

  • Gradient matters AS WELL as the most vulnerable. Proportionate universalism
  • Injustice itself is a risk.
  • Economic benefits of addressing – productivity loss, tax receipts, welfare payments, treatment costs
  • Social factors; fairness and distribution of power; access to meaningful work; wages, taxation and cost of living; education, training and employment, housing, public transport and amenities; Social and community networks; Individual lifestyle factors; Healthcare
  • The specific recommendations of marmot are NOT included in the table below, but noted in full further in this document

Marmot set out that reducing health inequalities will need action on 6 policy objectives:

  1. Give every child the best start in life
  • reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills.
  • Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient.
  • Build the resilience and well-being of young children across the social gradient.
  1. Enable all children young people and adults to maximise their capabilities and have control over their lives
  • Reduce the social gradient 1 in skills and qualifications.
  • Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people.
  • Improve the access and use of quality lifelong learning across the social gradient.
  1. Create fair employment and good work for all
  • Improve access to good jobs and reduce long-term unemployment across the social gradient.
  • Make it easier for people who are disadvantaged in the labour market to obtain and keep work.
  • Improve quality of jobs across the social gradient.
  1. Ensure healthy standard of living for all
  • Establish a minimum income for healthy living for people of all ages.
  • Reduce the social gradient in the standard of living through progressive taxation and other fiscal policies.
  • Reduce the cliff edges faced by people moving between benefits and work.
  1. Create and develop healthy and sustainable places and communities
  • Develop common policies to reduce the scale and impact of climate change and health inequalities.
  • Improve community capital and reduce social isolation across the social gradient.
  1. Strengthen the role and impact of ill health prevention
  • Prioritise prevention and early detection of those conditions most strongly related to health inequalities.
  • Increase availability of long-term and sustainable funding in ill health prevention across the social gradient.

The remainder of the blog sets out policy or intervention ideas led by multiple reviews of evidence over last 10 years.

Domain Intervention
Overarching

 

 

Source

Marmot, Smith

·          Introduce further national targets for reducing health inequalities

·          Routinely undertake health equity impact assessments on all policy in areas, including macroeconomic and fiscal policy, trade policy, foreign policy, ‘defence’ policy and international development

·          Pursue ‘Health in All Policies’ style approaches to policymaking

·          Pass responsibility for reducing health inequalities to a central government office, rather than to departments of health

·          Implement measures to protect the policy process and decision-making from interference by relevant commercial sector interests

·          Include socio-economic status as a protected characteristic of Equalities legislation

Tax / benefit, income

 

 

 

Source

Picket, Smith,  McAuley, Baum, Marmot, British Academy, NHS Scotland

·          Progressive systems of taxation, benefits, pensions and tax credits that provide greater support for people at the lower end of the social gradient and do more to reduce inequalities in wealth.

·          A 10% increase in the level of tobacco taxation.

·          Introduce a minimum price for alcohol products via minimum unit pricing

·          Institute measures to reduce economic inequity including more progressive income tax and taxes on wealth and inheritance. Tax capital gains at the same rate as income tax.  Introduce a cap on the wealth that any one individual can inherit

·          Introduce a tax on high sugar and high fat foods

·          Increase social protection for those on the lowest incomes and provide more flexible income and welfare support for those moving in and out of work (‘flexicurity’) – review of the systems of taxation, benefits, pensions and tax credits to achieve the reduction of ‘cliff edges’ faced by those in and out of work and facilitate flexibility of employment

·          Review the role of the tax and benefits systems to facilitate adherence to minimum income for healthy living standards

·          increase in the minimum wage.

·          Increase income support to the unemployed to a liveable level

·          Universal Basic Income

·          Require the highest paid employees of a company to earn no more than 20 times the salary of the lowest paid employees.

·          Hypothecate (earmark/ring-fence) portions of taxes on health-damaging products (e.g. tobacco, alcohol and petrol) for investment in health improvement, especially in poorer areas

Vulnerable populations

 

 

Source

Picket, Luchenski, Marmot

·          More resources in support for vulnerable populations, by providing better homeless services, mental health services and other social care.

·          Upstream policy measures to reduce material poverty and deprivation are crucial to prevent extreme social and health inequalities from occurring in the first place…..

·          Caseworking support and combination intervention approaches boost effectiveness in most groups.

·          Evidence for specific interventions for excluded young people is scarce, some evidence for fostering and mental health/criminal behaviour

·          Respite care (ie, short-term recuperative care for homeless individuals after hospital discharge) can reduce the number of future hospital admissions and use of emergency departments in homeless populations

·          Provision of housing improves a range of health and social outcomes for homeless populations, particularly among those experiencing mental illness and substance use disorders.

Children, families, best start, primary and secondary education

 

Source

Smith, Baum, Marmot

·          Dramatically increase investment in public early childhood education and affordable, quality childcare. focus on early development of physical and emotional health, and cognitive, linguistic, and social skills.

·          Provide routine support to families through parenting programmes, children’s centres and key support workers

·          Increase the proportion of overall government expenditure allocated to the early years and ensure this expenditure is focused progressively across the social gradient

·          Introduce policies which intensively focus on improving literacy among primary school children in deprived areas through one-to-one teaching for those with low reading scores

·          Invest more resources in state-funded education, with additional investments for schools serving more deprived communities

·          Target long-lasting contraceptives at young women in deprived communities

·          Provide paid parental leave in the first year of life with a minimum income for healthy living

·          Provide means-tested, state-funded childcare (similar to Sweden)

·          Prioritise reducing social inequalities in pupils’ educational outcomes.

·          Prioritise reducing social inequalities in life skills – Extending the role of schools in supporting families and communities and taking a ‘whole child’ approach to education, Consistently implementing the full range of extended services in and around schools,

·          Developing the school-based workforce to  build their skills in working across school– home boundaries and addressing social and emotional development, physical and mental health and well-being.

·          Foucs on building the the resilience and well-being of young children across the social gradient.

·          Support families to achieve progressive improvements in early child development – Giving priority to pre and post natal interventions including intensive home visiting, Providing paid parental leave in the first year of life with a minimum income for healthy living, Giving routine support to families through parenting programmes, children’s centres and key workers, to meet social need via outreach to families

lifelong learning

 

 

Source

Picket

·          View lifelong learning as a crucial investment and make all public education free

·          Reduce subsidises to private education. Require fee-paying (private) schools to allocate at least 50% of their places for non-fee paying children living in deprived communities

·          Provide easily accessible support and advice for 16-25 year olds on life skills, training and employment opportunities, delivered through centres that are easily accessible to young people

·          Provide further work-based learning for young people and those changing jobs/careers, including paid apprenticeships

·          Ensure access to higher education is affordable (e.g. by getting rid of tuition fees where they are in place)

·          Increase the availability of non-vocational life-long learning across the life course

Employment and work

 

 

Source

Picket, Marmot, Picket,

British Academy, Smith

·          More resources for active labour market programmes to reduce long-term unemployment and for in primary care health services in deprived areas to support routes to work. Make it easier for people who are disadvantaged in the labour market to obtain and keep work.

·          increase social protection for those on the lowest incomes and provide more flexible income and welfare support for those moving in and out of work.

·          Tackling Health-Related Worklessness: a ‘Health First’ Approach. Reconsider “work” as a clinically relevant outcome

·          Create public sector jobs to engage people at all stages of the lifecycle, and focus on job creation

·          Encourage, incentivise and, where appropriate, enforce the implementation of measures to improve the quality of work across the social gradient, – Ensuring that public and private sector employers adhere to equality guidance and legislation, Implementing guidance on stress management and the effective promotion of well-being and physical and mental health at work.

·          Develop greater security and flexibility in employment  – Improving flexibility of retirement age, Encouraging/incentivising employers to create or adapt jobs that are suitable for lone parents, carers and people with mental and physical health problems.

·          Improve implementation of measures to improve the quality of work across the social gradient – Improving job security built into employment contracts and ensuring employers adhere to equality legislation, extending stress management and the effective promotion of well-being and physical and mental health at work.

·          Ensure all public and private sector employers adhere to equality guidance and legislation

·          Encourage and incentivise employers to create or adapt jobs that are suitable for lone parents, carers and people with mental and physical health problems

·          Encourage and incentivise union membership and/or the development of worker co-operatives

·          Introduce stronger employment legislation, including greater support for trades unions and restrictions on ‘flexible’ insecure contract

Homes and housing

 

 

Source

Smith, Baum

·          Support an enhanced home building programme including in decent social housing to bring down housing costs.

·          View having a secure home as a right for all

·          Fuel poverty strategy. Improve the energy efficiency of housing across the social gradient. Provide subsidised fuel or fuel supplements for those on the lowest incomes to address fuel poverty

·          Repeal recent ‘bedroom tax’ legislation

·          Enhance the existing “Right to Sell” so that mortgagees have the right to stay in their home and become tenants rather than face eviction

·          Amend legislation so that illegal actions by landlords and banks that deprive people of their home become criminal rather than civil offences

·          Introduce rent controls (which would also reduce housing benefit bills)

·          Increase the taxes that apply to second homes, holiday homes and empty commercial property

·          Extend the current council tax bands up to band Z with a view to transforming the tax into a fairer national land and property tax

Transport and travel

 

Source

Picket, Smith, , British Academy, Baum

·          Reduce speeds in urban areas, starting with the poorest areas, especially to protect children and the elderly.

·          Create healthy urban environments which are safe, friendly to pedestrians and cyclists, and which encourage social interaction

·          Changes in the extent of active (walking and cycling) commuting to and from work

·          Provide (or maintain, where already provided) free public transport for people past the retirement age (to prevent social isolation)

·          Provide free public transport for all children

·          Increase taxes on petrol and diesel

Economic

 

 

Source

Baum, Marmot

·          Measure what we treasure and no longer rely on GDP as the measure of our progress. Instead, introduce a well-researched measure of wellbeing appropriate to our country

·          Encourage small and medium-sized businesses which show commitment to the local communities in which they operate

·          Determine which assets and resources should be either nationalised or privatised based on demonstrable long term public benefit

·          economic strategies should include an explicit aim to reduce income inequality gaps.

·          Develop inclusive growth strategy to stimulate local ecoomiy, within this public service anchor institutions have significant role.

Health care

 

 

Source

Smith, NAO, Baum, McAuley,  PAC 2010

·          Invest more resources in primary care health services serving very deprived areas. address  the GP shortage in the areas of highest need, This inequity in the resource allocation for General Practice creates structural inequality. imbalances in the funding received by individual practices (relative to need),

·          Invest more resources in support for vulnerable populations, by providing better homeless services, mental health services, etc.

·          Deep end Manifesto. A good a place to start. Needs to be turned into specifics

·          increase the prescribing of drugs to control blood pressure by 40 per cent, cholesterol control similar

·          double the capacity of smoking cessation services – especially in a focused targeted way

·          Greater provision of alcohol brief interventions (ABIs).

·          Ensure universal access to high quality and appropriate, publicly-funded health care, and progressively make community-controlled primary health care the backbone of our system. This system will focus on cure, rehabilitation, prevention and promotion

·          Invest in the evaluation of new medical technologies to ensure they have more benefits than costs

·          Eliminate subsidies to private health insurance and invest funds in the public health system

·          address the low proportion of NHS budget (<4%) allocated to prevention.

·          Models of care focused on burden of disease and population, not service focused, and a focus on populations, neighbourhoods and communities that is organisationally agnostic is more likely to be pro equity than the current model.

·          START with need and use equity audit to highlight inequity between need, service use and outcomes. Approach to equality to go beyond protected characteristics (ie in the legisltation) and cover with equal weight the other aspects of vulnerability (deprivation, homelessness, abuse). Tool to focus on the people we aren’t reaching. Need to be more granular and precise in identifying who the target population is beyond the catch all “hard to reach”.

·          Agree and enact a principle of a disproportionate offer and resourcing (to meet disproportionate need). Measurable indicator is financial – what % of the NHS £ is witin primary care.

·          Role of NHS as economic anchor.  Don’t neglect the notion of inclusive growth, a sustainable economy and the role of the NHS as an economic anchor institution. This in itself is worth further work as has many facets.

Other

 

Source

Smith, British Academy, Baum, Marmot

·          Fluoridate domestic water supplies (where this is not already done)

·          Building Age-Friendly Communities

·          Prioritise policies and interventions 1 that reduce both health inequalities and mitigate climate change – Increasing active travel across the social gradient, access and quality of open and green spaces available across the social gradient, Improving local food environments across the social gradient

·          Reduce the availability of tobacco products (both legal and illicit)

·          planning controls that ensure the most unhealthy food is not so readily available in the poorest places, tax on sugary drinks – perhaps hypothecated for research into behavioural insights on who still smokes and why

·          Restrict lobbying by powerful interest groups by creating a transparent register of lobbyists, and capping donations to all political parties. Regulate corporate behaviour so that transnational corporations can’t externalise costs of poor occupational health and safety, environmental degradation and unsafe and unhealthy products. measures to protect the policy process and decision-making from interference by relevant commercial sector interests (e.g. alcohol, tobacco and ultra-processed food manufacturers and retailers

·          Make our policy development processes as participatory as possible, and encourage groups with little economic and social power, in particular, to be meaningfully engaged. Using Participatory Budgeting to Improve Mental Capital at the Local Level

Other specifics re food, alcohol, tobacco control

MUP, or alcohol tax increases, Restrict the availability of alcohol products via further licensing restrictions, further restrictions on the marketing of alcohol products (e.g. ban on TV advertising), complete ban on the advertising of alcohol products, Provide incentives for retailers in poorer areas to promote healthier food products, Ban trans fats in all foods, Provide free, nutritious school meals for all children in state schools, Restrict advertising of ultra-processed / high fat / high sugar food and drinks (e.g. introduce a ban on TV advertising before the watershed), Implement a complete ban on the advertising of ultra-processed / high fat / high sugar food and drinks, Increase the price of ultra-processed / high fat / high sugar food and drinks via taxation, Reduce the availability of tobacco products (both legal and illicit), Increase the price of tobacco products via tax increases, Introduce standardised packaging of tobacco products (i.e. remove branding), Legislate for smoke-free cars, Legislate for smoke-free homes

References

Picket https://peg.primeeconomics.org/policybriefs/population-health-reduction-of-health-inequalities

Marmot – http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

Smith et al https://www.ncbi.nlm.nih.gov/pubmed/25174045

British Academy. http://www.britac.ac.uk/publications/if-you-could-do-one-thing

Public Accounts Committee 2010. https://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubacc/…/470.pdf

NAO – https://www.nao.org.uk/report/tackling-inequalities-in-life-expectancy-in-areas-with-the-worst-health-and-deprivation/

McAuley A http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159256

Baum – https://croakey.org/beyond-the-social-determinants-a-manifesto-for-wellbeing/

Luchenski,- inclusion health, what works http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31959-1.pdf

NHS Scotland – Modelling the impact of policy interventions on income in Scotland

Glasgow / Deep end

First published on the Sheffield DPH blog

Tagged | Leave a comment

Introduction

This is the first in a set of two blogs attempts to describe the story of health inequalities in a town and recent history, why this remains important, what a strategy might look like and how it might be framed.

Blog 1 considers the story in Sheffield to date, framing, context and language, the impact of systematic strategy.

Blog 2 will cover general approach to intervention and specific actions or interventions we should implement.

Blog 3 will cover the perspectives of two jobbing GPs working at the sharp end of this

Blog 4 will cover some thoughts on where next

I’m sorry it’s a bit long and complex ………

  1. The story in Sheffield to date

How do we do?

Inequalities in health outcomes in Sheffield are well documented: there is a 20 – 25 year gap in healthy life expectancy between best and worst along the normal dividing lines of deprivation,  mental health, learning disability, ethnicity, etc.  The Marmot indicators, which outline this in more detail, can be found here.  They were replaced in 2016 by the PHE Wider Determinants Tool.  This includes a “Marmot Indicators” domain.  This paper will not discuss these further for brevity.

The current strategy for Sheffield

Sheffield has a Sheffield Health Inequalities Plan agreed in 2014.  The plan was lifted straight from the Joint Health & Wellbeing Strategy (JHWBS) and is made up of all the recommendations in the JHWBS that refer to health inequalities.  The JHWBS itself arose from the JSNA.  It wasn’t something separate and different: putting health inequalities into a separate plan was supposed to make us all focus explicitly on health inequalities.

In retrospect, most seem of the view that it didn’t achieve that objective; something similar could be said of the JHWBS.  It’s a little old now, and all acknowledge there is a need to revise or rewrite it.  We all know that health inequalities as one of its most important priorities.  We mostly accept there are no simple easy solutions.

The Sheffield HWBB has held two recent discussions, in December 2015 and June 2016.  The December 2015 meeting focussed on quantifying the challenge, while the June 2016 meeting focused on agreeing a refreshed strategy; building on the 2014 plan.  In June 2016 there were five areas of focus, reflecting a need for interventions with a short and long term return:

  • Continued commitment to an asset based community development based approach to health and wellbeing
  • Continued investment in and commitment to primary care and within this General Practice services, especially in the most disadvantaged parts of the city
  • Continued commitment to the principle of implementing effort and change where greatest need is identified
  • Refocused effort on the link between employment and health
  • When looking at “healthy lifestyles” focus on the environment and make the healthy choice the easiest and default choice.

Clearly these  five areas highlighted were not the only answer to the difficult issue of health inequalities; rather, these were the areas where the Board agreed to focus first.

The Board also requested that emphasis be given to the concept of moving from an equal offer to a differential offer with a view to achieving an equitable outcome.  This implies a tailored response to greater need.  Finally it’s important to recognise the set of things that can be changed at Sheffield level whilst recognising the continuing need for on-going pressure for national change.

It’s not just about deprived geographical communities

A focus on both geography and specific population groups is needed.  The geography issue is broadly a point about socioeconomic deprivation, but it is important to note that this is not just about “the poor” but other excluded groups as well.  Other important groups include homeless individuals, prisoners, sex workers and people with substance use disorders, to name just a few.  Of course, these populations can overlap: for example, substance use disorder is common in other socially excluded groups.  There are many other groups with substantially poorer outcomes than the population average.

The Board also identified that specific population groups require additional focus including, for example: children and young people, BME groups, those with learning and physical disabilities and those experiencing mental health problems.  This was a specific issue around vulnerable groups of people, including but not limited to the protected groups identified in equality legislation.  The advantage of a double and layered approach is that it allows for multiple inequalities to be handled at the same time.

There is a wider context

The three themes of Due North (Poverty and economic inequality; Healthy development in early childhood; and Share power over resources and increase public influence over decisions) are still pertinent.  The Due North analysis is essentially a socio-economic one which builds on this to make the case that economic inequity leads to alienation.  Due North argued for the need to  strengthen the role of the public sector and tried to address the complexity in this by talking to three different agendas (regionalism and government structures, greater transparency of decision making at a local level and collective forms of ownership).  Arguably Due North was weak on the role of the community and voluntary sector, especially grass roots community organisations.

There is a much broader context across the city also.  The single biggest factor driving the health gap in the UK is the wealth gapThere are also substantial work streams around issues of direct relevance to health inequalities: work on inclusive growth, the Fairness Commission, and SCC’s/City work on poverty, to name just a few.  Relevant strategies in other policy domains are in place, but these may be partial and disconnected – financial security, community stability, community coherence – all need to be pulling together.

  1. Why it remains important
  • Injustice in itself;
  • Social cohesion – Marmot suggests that in societies with substantial inequality the considerable gap between the top 1% of income earners and the rest of society threatens social cohesion;
  • Important factor in the slowing down of improvements in Life Expectancy and Healthy Life Expectancy;
  • HWBB (and the partners involved) has a legal requirement to address inequality in access and outcomes – See here.
  • Not addressing demand will lead to costs to the state that are unfunded and storing up problems for the future. This can be thought of as addressing diabetes vs obesity vs the determinants of obesity;
  • This is NOT a side issue, it is a population issue. Inequalities are bad for ALL of us – we’re ALL worse off as a consequence.  It’s not just about the most deprived.  Inequality is a societal issue: when expressed in terms of the economy, inequality is a drag on total societal production.  The same may well apply to wellbeing, such that inequality in wellbeing is a drag on total societal health and wellbeing.  Societal health and wellbeing is then a driver of demand for services;
  • It is not only a public funding issue but public funding is an important social protection and source of investment in things the market won’t provide.
  • From an NHS perspective, inequity in morbidity (and multi morbidity) is driving demand, expressed in terms of consequences for the health care system, with a 15 year differential between the most and least deprived in the onset of multi morbidity. We can document this in Sheffield and it is a driver of demand for public services. I’d encourage readers to consider my take on the  the most important charts in health care, particularly chart 2, 3 & 4. This is where the demand in your health and social care system is coming from. I’ve blogged on that. A lot. And won’t repeat all that here
  1. Why has there been limited to no progress?

Nobody underestimates the difficulty of moving some of these debates forward, because there are no easy or simple answers.  Measurement is easy and talk is easy, but concrete progress is difficult.  Reasons for this limited progress include:

  • There isn’t a burning platform for the issue that everyone aligns around – the money. Whilst there’s  a platform around social justice, amongst other things, this is not connected to the demand and resource implications of inequalities; Addressing health inequalities is not seen as mission critical to the business.  There isn’t a “business case” clearly written and articulated on it.  However, until we sort out wealth inequality there is limited/to no point talking about economic productivity;
  • Differential resourcing is very difficult, politically and operationally;
  • The wider context is exceptionally challenging. We are facing the most challenging outlook for public services since the 1970s.  Pre-Brexit, the signals were that austerity would continue into the 2020s; post-Brexit, no economics textbook in the world says that a decade of uncertainty is a good thing.  This has clear implications for public services that are incredibly dependent on the economic cycle.  Austerity is certainly making inequalities worse not better, through direct impacts on individuals and the indirect result of cutting the social security safety net.  It has been well documented that the impact of austerity is worse in areas that are more deprived ([1],,[2][3]).There is also a layering effect of multiple cuts on families.  The 40% Local Government cut will and is directly affecting the things that determine health of individuals and communities (such as the closure of Surestart Centres).  We can’t keep cutting and expect nothing to happen.  It would appear that both quality and length of life is deteriorating as we get deeper into the impact of austerity;
  • Beyond austerity, the resource allocation formula itself has created inequality;
  • Governance: the current challenge needs stable long term government.  We have a minority government: history (1970s) suggests it will last, but that the government will be thinking in days and weeks, not months, years or decades.  There is a need for a fundamental realignment of systems but in a minority government, the overriding mind set will be “is it contentious?”  Realigning priorities is contentious and thus likely to not happen.  At the local level, governance is messy, with differential levels of devolution, financial challenges and limited stability.  Grenfell Tower is an obvious and emblematic tragedy and profound in governance terms.  It has challenged all of us as we have created an “efficient” delivery system through outsourcing leading to fragmentation where nobody is in control, and leaders have no line of sight and no real control.
  1. Language and framing of health inequalities. It matters

There is value in being clear about how we understand and talk about the issue that is health inequalities, including the words and framework we use.

The issue could be Framed around the following domains (not necessarily in order of importance before anyone gives me grief):

  • Our health behaviours and lifestyles
  • Wider determinants of health
  • Communities and health
  • An integrated health and care system

The Marmot areas of recommended policy focus remain the benchmark:

  • Enable all children, young people, and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure a healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities;
  • Strengthen the role and impact of ill health prevention.

It may also be framed around life course (starting well, living well, ageing well) and in terms of services for people and places where people live. 

There is also merit in bringing together the various strands around equality, poverty, inequality and similar as many of them cover similar space

What words do we use matter

The language of “health inequalities” might benefit from simplification: Consider the impact of “health inequalities” vs “poorer health and shorter lives”.  There is a need for language that communities really engage with.  The Robert Wood Johnson Foundation have done some interesting work in this space, as have the Frameworks Institute, specifically here.  In discussion with residents, there will likely be a focus on their priorities relating to the here and now.  Getting public focus on health inequalities might take some doing.

What framework do we use?  Julia Lynch makes the case of the danger of “medicalising” or individualising heath inequalities:

ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.  Medicalizing inequality is appealing to many, more appealing than tackling income and wage inequality head-on.  But it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve.  Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities”.

Similarly Marmot points out that evidence on “tackling” health inequalities tends to be focused on the biomedical model paradigm and evidential thinking.  Marmot recently noted that “downstream” interventions have been covered, for the most part, in the scientific literature.  There has been much less focus on structural interventions.

If one went purely by the numbers of papers published, one would put effort into pharmacological treatment and would ignore housing; emphasise case management and ignore poverty”.

We need to be clear that “Health” does not mean the same thing as “the NHS”.  We should define the differences between “Health”, “NHS” and “Social Care” vs “Health” and “Wellbeing”.  Using the narrative being promoted by Prof Burns on salutogenesis (what causes good health) vs pathogenesis (what causes ill health) could help.

Determinants are not inequalities and vice versa.  The term “determinants” is one way of expressing the risks to health and wellbeing.  They are upstream risks, assets or protective factors.  Both upstream and downstream factors matter, but we should start from the position that upstream factors matter more.  Inequity is the differential distribution of these factors.

Health inequality is therefore about:

  1. The unequal distribution of clinical and lifestyle risk factors (a small part of which is about the NHS)
  2. The unequal distribution of social and environmental risk factors (the determinants)
  3. The determinants of the determinants (power, concentration of wealth, dominant economic model etc.)

Health inequalities are not a “health” thing, or indeed a “public health” thing.  The consequences of “health inequalities” are social and specific to the NHS only in terms of demand.  Some argue in this context that the Department of Health & Social Care is the wrong sponsor agency, as it is responsible for the consequences of failure rather than the solutions.  There is also a danger that DHSC sponsorship will tend to lead to health service design solution thinking first.

The causes are largely upstream of the NHS.  There are local, regional and national aspects to the solutions, especially in terms of skilled advocacy and challenging conversations with other parts of government, and the economic, social and political ideologies that make the inequitable distribution more likely: the determinants of the determinants.

  1. The impact of a deliberate strategy: is it worth the effort?

Yes.

From a number of viewpoints. If you don’t care about social justice and important stuff like this, and only care about demand for services and money – I’d encourage you to very carefully consider the last two bullet points in section 2 above. This directly links inequality to demand, and illustrates why it’s not just a soft fluffy social policy issue.

Barr highlighted the positive impact of a deliberate strategy at national level, considering geographical health inequalities measured as the relative and absolute differences in male and female life expectancy at birth between the most deprived local authorities in England and the rest of the country.

The analysis suggests that prior to the introduction of the English Health Inequalities Strategy, geographical differences in life expectancy and health were widening.  During the implementation of the strategy, these trends were reversed but since this program ended there is evidence to suggest the improvement is being undone.

The period of the strategy encompassed a time (up to 2008) of increased public spending, economic growth and stability, relatively low unemployment, and increased investment in both healthcare and programs that addressed the wider determinants of health.

There was not always a clear distinction between policies that were part of the health inequalities strategy and policies that would have happened anyway in the absence of the strategy.  However, this period of increased social investment across the whole of government, targeted at disadvantaged areas and groups, was associated with a decline in health inequalities and geographical differences in life expectancy.

The end of the strategy and the start of the austerity program which reversed many of the key policies occurred at the same time, and therefore the effects of the program ending and austerity starting cannot be separated out.  However, there is clearly a stark contrast between a time when investment in policies which addressed the wider determinants of health resulted in a reduction in geographical differences in life expectancy and health, and the current policy environment which may be reversing those trends.

The reductions in the gap between best and worst were circa 1 year, which is hugely significant given the population nature of life expectancy. Think of the number of life years involved in such a change in life expectancy, then think about the morbidity – and thus lost productivity economically speaking and heath / social care use that preceeds  death.

References.

1 See here for evidence in strong gradient  in correlation between LA cuts and deprivation local authority level analysis from CRESR report (those with most need in population worst affected)

2 See here for impact of welfare reform split in other ways from Equality and Human Rights Commission report

3 See also Liverpool John Moores – Welfare reform, cumulative impact analysis 2017

First published on the Sheffield DPH blog

Tagged | Leave a comment

A video of this presentation is available

The Health and Well-Being Board A forum for discussion and asking questions

  • Ask about population health, and wider determinants of health – implications
  • Health priorities and commissioning
  • Check -good measurements of need and service, ask for profiles of health
  • Communication with other depts of the council

Outputs;

  • Joint Strategic Needs Assessment,
  • Health and Well-Being Strategy (every 3 years)

Joint Strategic Needs Assessment is online, available to everyone and updated

Information-  is it fit for purpose?

Obtain and share Public Health Information data in your Local Authority –analyse it -produce local, timely evidence, discuss

health profiles, maps, time trends, wider determinants and comparative data across Local Authorities, Counties, Regions and across England for best commissioning, to improve health and reduce inequalities

Health is everyone’s business – towards Healthier Lifestyles

  • Local Government Association Peer Challenge

  • Prevention agenda
  • Social Prescribing
  • Learn from other Local Authorities
  • Enable communities to be healthy
  • Scrutinise Public Health Intelligence in times of austerity- priorities

Key Health Areas:

  • Stop smoking
  • Reduce obesity,
  • Increase exercise,
  • Sensible drinking,
  • Improve sexual health,
  • Improve mental health (Child and Adolescent Mental Health Services)

Public Health Intelligence is  the key to reducing Health inequalities  & Inequity – get involved !

Health in all Policies

What are our health priorities for the next year?

Look at  the evidence:

Childhood obesity

Childhood obesity

Preventable Premature Cancer

Preventable Premature Cancer

How does your area compare with other similar places?

Health and Social Care + wider determinants of health

  • Health Scrutiny Committee
  • Public health, Prevention and Performance
  • Adult Social Care
  • Children’s Services
  • Environment + Planning +Transport
  • Housing (community infrastructure)
  • Education & Libraries
  • Community Safety and waste management

Public Health Intelligence & the Marmot report

Tools to investigate

Robust  statistical methods to give  evidence to change local health policy

  • Health Needs Assessment (JSNA) ;
  • Health Equity Audit;.
  • Time trends, Comparisons
  • Priorities;
  • Cost-effectiveness;

Inequity?

  • Inequality – the difference in the distribution of a health measure (by person or place)-univariate measure
  • Inequity – an inequality in the distribution of health intervention in relation to health need that is considered unfair -bivariate

Inequity :  those with most need get the lowest level of service- the undesirable “inverse care law” (this case even worse than negative linear relationship)

inverse care law

Equity : high need is matched by high service provision- the desirable situation

Equity

Health Equity Audit  cycle

Audit cycle

Health Equity audit: Smoking among   St Albans PCT males

St. Albans had the lowest overall Standardized mortality ratio in the region and was considered a “healthy, rich  PCT”.  But this figure and the high quit rate of  68% disguised the inequity of uptake of smoking cessation services between wards within the PCT. The negative gradient of regression line (although low r) indicates poor wards with high Smoking Attributable Mortality (SAM) have  low or zero smoking cessation uptake.”.. Ie inverse care law. The stop smoking services then got moved to be located in low and zero SAM wards ( into church halls and a pharmacy – not GP centres) – and the gradient was reversed over the next 3 years – and gradually SAM reduced In Sopwell ward smoking attributable mortality was high and smoking cessation uptake is recorded as zero.

The quit rate in itself is not enough.  We can use data for more accountability locally to improve health.

Health Equity Audit in St.Albans: Male smoking cessation uptake v .smoking attributable mortality  for all males age 35 years and over between 1998 and 2002   

Quit Rate= 68% (2002-3)

After

Measure the Smoking cessation uptake  and Quit Rate by ward.  

We should use % Uptake from high Smoking Attributable Mortality areas as targets rather than quit rate alone, to measure service success.

Partnership
Communicate health needs with other depts of council- eg transport, housing

Share Health  Intelligence

Integration and Partnership working with other directors,and depts in the local authority,  CCGs, Voluntary sector Hospitals , Community Trusts  and other Local Authorities

Collaborations to save costs- win, win!

Eg cycling, walking bus, – exercise, lower carbon footprint, reduce obesity- etc… but safety?  are cycle lanes in place… argue the  business case- to save costs later.,

Listening,  and Participating in  Communication

Asking questions

Politics, Elections in May 2018  can push  key health message priorities through the Health and Well-Being Board.

  • Understanding wider determinants of health Councillors next May -money going to  poorer health places and people
  • Money spent appropriately on evidence based interventions
  • Understanding, listening and speaking the same language as the community with poor health to be reached

Childhood  and Adult Obesity

Local Authorities need to know their wards  of most need

  • Joint responsibility health, education, transport, sport, green spaces, fast food outlets, shops.
  • Data – Information –Public Health Intelligence –communication-partnership – intervention- monitor data, (PHI) record evidence of improvement (or not)-
  • Evidence of what works .
  • Schools approach for children?

CHANGING CHILDREN’S LIFESTYLES – Reducing Childhood Obesity

Measuring a child

Summary of Findings since 2006 :  Children’s body mass index in Barking and Dagenham Age 5 and 11 with

School nurses from Barking and Dagenham Collecting data for the National Child Measurement Programme

Childhood Obesity in Year 6:

Prevalence of obesity

Change in rates of obesity

Councillors can improve health by knowing the needs in their own patch, using Public Health Intelligence,  asking key questions &  becoming health champions in every dept of the council, Health in all policies, and with partner organisations!

Leave a comment

Our meeting yesterday at the Labour Local Government Conference captured on video

Labour Local Government Conference from Policy Review on Vimeo.

Chaired by Steve Bullock, Lewisham

Speakers:

Cllr Tina Dopson, Essex

Cllr Margaret Eames-Petersen, Hertfordshire

Cllr Paul Brant, Liverpool

Tagged | Leave a comment

You can review the presentations from our recent conference on public health:

We asked each speaker to propose no more than five priorities. Some of them, happily, coincided and I’ve only chosen one where their seemed to be a substantial overlap.  Prof Nazroo didn’t feel able to produce five simple proposals and Tim Lang is not yet ready to release his priorities to public scrutiny.   But we still have a lot more than five.  So you are invited to decide which are  your top five priorities.  I’m afraid I have mangled some of these ideas to get them short enough.  So these words are mostly mine, rather than those of our distinguished contributors. I apologise but that is what happens when you try and produce evidence based policies and get involved in the messy business of politics.  The subtleties get lost.

Public health priorities

  • Develop universal, comprehensive, high-quality early Childhood care and Education. (10%, 8 Votes)
  • Invest in our public health workforce (10%, 8 Votes)
  • Ensure resources for health are distributed to reduce inequalities in life chances between places. (10%, 8 Votes)
  • Move from Financial Reporting to Financial, social and environmental reporting (9%, 7 Votes)
  • Invest in local public health services (8%, 6 Votes)
  • A new public health bill to give more state power against threats to health (8%, 6 Votes)
  • Implement existing laws that protect conditions that create and protect health and fairness (6%, 5 Votes)
  • Increase the public health benefits of the social security system. (6%, 5 Votes)
  • Measure value and benefit, not just cost of sustainable interventions (5%, 4 Votes)
  • Radical overhaul of gambling regulation (4%, 3 Votes)
  • Minimum unit pricing for alcohol (4%, 3 Votes)
  • Levys on the unhealthy commodity industries (4%, 3 Votes)
  • Build an energy economy based on renewables. (4%, 3 Votes)
  • Review of the marketing of unhealthy commodities and services to children, young people and the vulnerable (4%, 3 Votes)
  • New trade agreements to protect and promote the publics health (3%, 2 Votes)
  • Devolve power – increasing the influence that the public has over how resources are used. (3%, 2 Votes)
  • Redefine community health and prosperity beyond materialism (3%, 2 Votes)
  • Invest in public transport (1%, 1 Votes)
  • Take cycling seriously. Invest in infrastructure (1%, 1 Votes)
  • Default 20mph speed limit nationally for residential streets (0%, 0 Votes)
  • Stop blaming do something about our environment so that it’s easier for us to live healthier and longer. (0%, 0 Votes)
  • Better road crossing facilities – more crossings, more time (0%, 0 Votes)

Total Voters: 17

Loading ... Loading ...
2 Comments

Non Communicable Diseases are the biggest cause of mortality, morbidity, disability, healthy life years lost and a major cause and consequence of health inequalities

The priorities for action should have the biggest impact, the shortest timescale, be most sustainable, most equitable in reducing health inequalities and injustices for the vulnerable and across generations, achieve the maxim co-benefits for the environment and reducing demand on public services and realisation of human rights.

Linked Avoidable Non Communicable Diseases and conditions:

  • CHD and Stroke -cardiovascular
  • Circulatory diseases
  • Cancers
  • Respiratory diseases
  • Liver disease
  • Type 2 Diabetes
  • Kidney disease
  • Obesity
  • Neurovascular and mixed Dementia
  • Musco-skeletal etc.
Deaths by cause in UK men 2014

Deaths by cause in UK men 2014

Impact on healthy life expectancy and life expectancy

Non Communicable Diseases are a cause and manifestation of health inequalities in current and future generations.  These are diseases that “break the bank “

Impact on economic growth and sustainability of public services

  • Estimated at $47 trillion over the next two decades.Approximately 75% of the 2010 global gross domestic product (GDP). Source: World Economic Forum / Harvard School of Public Health. 2011
  • Alter demographics
  • Stunts country level development
  • Two –punch blow to development- national economies and individuals in poverty
  • Not a mark of failure of individual will power, but politics at the highest level

What are the real determinants of this spread?

Multi-national capitalists

  • Transnational corporations are major drivers of NCD epidemics and profit from unhealthy commodities
  • Public regulation and market intervention can prevent harm caused by unhealthy commodity industries

Public health measures

Some key potential priorities for consideration:

  • Something like the  Office for Budget Responsibility for the Public’s Health
  • A comprehensive review of the marketing of unhealthy commodities and services to children, young people and the vulnerable
  • Levys on the unhealthy commodity industries to provide additional public health funding to cover the societal costs as well as reduce their consumption
  • Ensuring new trade agreements protect and promote the publics health
  • A new public health bill – the state has powers to monitor in real time the commercial risks to the publics health, to ensure the state has (reserve)powers to tackle unhealthy commodity industries and services, set out duties for public bodies to consider the health of future generations and the planet and address health inequalities and the right to health

An OBR for health?

  • Health should be properly considered in all fiscal, economic and market policies (human and planetary ill health and poor wellbeing are anthropogenic)
  • Sustainability of Public Services especially the NHS and social care (“the miscalculation of sublime proportions”). NHS is set to cost 1.6 times GDP by 2065
  • Health as an asset to prosperity and productivity- Health Creating (not damaging) Economy
  • Focus on health life expectancy and health inequalities
  • House of Lords review – Sustainability of NHS and Social Care (2017) proposed an  Office for Health and Care Sustainability
  • Mechanism for health in all policies
  • Minimum Unit Price alcohol/Air Pollution etc.
  • Lead technical Agency – Public Health England

Processed food marketing and promotions:

healthy food

 

The recommended diet vs the advertised diet

Around three-quarters of food advertising to children is for sugary, fatty and salty foods. For every £1 spent by the WHO promoting healthy diets, £500 is spent by the food industry promoting unhealthy foods

We need a comprehensive review of the marketing regulators and codes

  • Regulators and codes not fit for purpose
  • Regulators essentially accountable to industry – self regulation
  • Statutory instruments focus on protecting market and plurality and the protection publics health is a low order objective
  • Action is after the event and codes are produced by the industry so are not effective as their production is conflicted
  • Self regulation is a failure for children, young people and the vulnerable

Unhealthy commodity Industry Levys

  • Could be applies to tobacco, alcohol and ultra processed food products and services (gambling etc.)
  • Reduce consumption
  • Some of these industries pay little tax- needs reviewing
  • Pay for the externalities and provide additional funding for public health
  • Sugar Drink Industry levy – way forward – Minimum Unit Pricing of alcohol in England
  • Tobacco – estimated £500 million- support for tobacco licensing scheme, smoking cessation support, Social marketing, Tso’s regulatory support etc.

We need a new Public Health Act. The last one was in 1936. The legislation addresses the epidemics of yesterday

  • Non Communicable Diseases  require new forms of health protection
  • Duties for Public Bodies – consider health of future generations and the planet and address the causes of health inequalities
  • Realisation of human rights (Social rights and the progressive realisation)
  • Statutory monitoring and surveillance of unhealthy industries and services
Dieselgate

#Dieselgate

Trade agreements have an effect on health. They could be used to protect our health.  We could learn from the experience of other countries.

Some key potential priorities for consideration:

  • An OBR for the Public’s Health
  • A comprehensive review of the marketing of unhealthy commodities and services to children, young people and the vulnerable
  • Levy’s on the unhealthy commodity industries to provide additional public health funding to cover the societal costs as well as reduce their consumption
  • Ensuring new trade agreements protect and promote the publics health
  • A new public health bill – the state has powers to monitor in real time the commercial risks to the publics health, to ensure the state has (reserve) powers to tackle unhealthy commodity industries and services, set out duties for public bodies to consider the health of future generations and the planet and address health inequalities and the right to health

More details in the proposals for a health-creating economy. 2017. UK Health Forum

This was presented at our conference Public Health Priorities for Labour

Tagged | Leave a comment
%d bloggers like this: