Category Archives: Public Health

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.

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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

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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

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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!

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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

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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

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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

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Labour’s Health Inequalities strategy had some success

Trends in life expectancy

Trends in life expectancy in the most deprived Local Authorities and the rest of England and the absolute difference 1983-2015.

What can we learn from the experience of the programme?

Good points:

  • Cross government
  • increase in equitable investment.
  • Progress on child and pensioner poverty.
  • Technical support for local action.

Bad points

  • Top down.
  • Ignored mental health inequalities.
  • Didn’t address income inequalities, disability poverty.
  • Didn’t empower disadvantaged communities

Priority 1.

Ensure resources for health are distributed to reduce inequalities in life chances between places.

Experience of getting the resources to the right places:

NHS & Local Authority funding per head

NHS & Local Authority funding per head 2002-2016

Funding in London

London does better than the rest of England

What was the impact of the NHS resource allocation policy from 2001 to 2011?

Cuts in council budgets

Cuts in council budgets 2010-2015

  • Review and simplify current systems for allocation of public resources to local areas.
  • Reinstate health inequalities objective for the NHS resource allocation policy.
  • Make reducing inequalities an explicit objective of local government and education allocation formulae.
  • Progressively shifting more resources to disadvantaged places.

Priority 2.

Devolve power – increasing the influence that the public has over how resources are used.

The Devolution Deception

The Devolution Deception

Radical devolution

Priority 3.

Increase the public health benefits of the social security system.

Public Health Toolkit

The benefits budget is twice as big as the health budget

Who gained most….

Poverty trends 1994-2014

This 10 year rise in absolute poverty is unprecedented since records began

  • Prioritize reducing child and disability poverty.
  • Ensure benefit payments provide an adequate income for healthy living.
  • Ensure the benefit processes is supportive and treats people with respect.
  • Reduce conditionality and sanctions.
  • Evaluate the health impact of any changes to the benefits system.

Priority 4.

Develop universal, comprehensive, high-quality early Childhood care and Education.

  • Extend the 30 free hours to all two-year-olds.
  • Provide affordable high-quality childcare through direct government subsidy.
  • Progressive investment to ensure that the places exist to meet demand.
  • Transition to a qualified, graduate-led workforce, by increasing staff wages and enhancing training opportunities.
  • Extending maternity pay to 12 months
  • Halt the closures and increase the amount of money available for Sure Start

So my 4 Priorities for Health Inequalities:

1.Ensure resources for health are distributed to reduce inequalities in life chances between places.

2.Devolve power – increasing the influence that the public has over how resources are used.

3.Increase the public health benefits of the social security system

4.Develop universal, comprehensive, high-quality early Childhood Care and Education.

national health inequalities strategy

and Re-establish a national health inequalities strategy.

This was presented at our conference Public Health Priorities for Labour

 

 

 

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Climate change is here. With just over one degree of average global warming above pre-industrial levels we can already see the consequences including increased storms, droughts, heat-waves, polar and mountain ice loss and sea level rise. Atmospheric CO2 levels are now at a level higher than that experienced by any person ever. People worldwide are losing lives and livelihoods already.

Fossil Free

The 2015 Lancet Commission on Health and Climate Change concluded that, “climate change threatens to undermine the last half century of gains in development and global health”. They noted that,

“The direct effects of climate change include increased heat stress, floods, drought, and increased frequency of intense storms, with the indirect threatening population health through adverse changes in air pollution, the spread of disease vectors, food insecurity and under-nutrition, displacement, and mental ill health.”

We know that burning fossil fuels is the major contributor to CO2 pollution and global warming. For even a miserable 50/50 chance of avoiding 2 degrees of warming 80% of known fossil fuel reserves have to remain unburnt. This represents a “carbon bubble” of stranded assets.

Yet the fossil fuel companies continue to seek new reserves and to exploit the existing ones. Many are also serial human rights abusers and climate change denial conspirators.

Council pension funds collectively hold some £295 billion of assets invested mainly in stocks and shares. This provides returns from which pensions are paid. These investments include significant exposure to fossil fuels: £16.1B or 5.5% of their assets. There are also significant investments held by universities and health organisations such as the British Medical Association and the British Psychological Society.

One the one hand, by continuing to plough funding into the fossil fuel industry, we remain locked into a fossil fuel future. On the other hand, if action is taken to prevent the exploitation of unburnable fossil fuels, then institutions are sitting on stranded assets (as the Bank of England has warned). In the case of pension funds, this means that the future of pensioners, future pensioners, their families and neighbours is threatened, as well as that for all citizens globally. Moreover, taking a financial hit on these assets will mean that to pay pensions, already stretched councils would have to dip into their budgets.

Local government these days has public health responsibilities. It is this that has led to some funds divesting from tobacco (but not all – Hackney is increasing its tobacco investments). The reputational and liability risks are arguably there with fossil fuel investments too: already oil majors are facing collective lawsuits for their negligence and conspiracy. Discharging their “fiduciary duty” is consistent with taking climate and other environmental and social risks into account, thus going beyond a narrow focus on financial returns: The Pensions Regulator has confirmed this understanding following consultations by the Law Commission and the DCLG.

Some pension funds in the local government scheme are showing the way with commitments to total or partial divestment: the Environment Agency Pension Fund, Haringey, Hackney, Waltham Forest, Southwark, and South Yorkshire. Others are dragging their feet with as much as 10% of their holdings in fossil fuels. Think what good those billions could do in the local and environmentally friendly economy, positively improving the health and well-being of the population.

Already Unison and the TUC have adopted fossil fuel divestment as policy.

Last weekend at its AGM, the SHA’s sister socialist society, SERA – the Labour Environment Campaign, also agreed to support these actions and work with the labour movement to promote fossil fuel divestment as a practical approach to reducing both environmental and financial risk.

SHA members can support the fossil fuel divestment campaign in a number of ways.

Fossil Free UK coordinates campaigns for local government pension funds to divest: find out how exposed your fund is at this link.

Medact campaigns for fossil fuel divestment by health institutions and has an excellent practical guide at this link.

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My priorities for Health Behaviours …

  1. Change the language!
  2. More controls on junk food marketing to kids
  3. Minimum unit pricing for alcohol is a must
  4. Start taking cycling seriously
  5. Betting. When the ‘fun’ stops

Liverpool

This is my city

It is not a rich city!

Do not blame us about how we live or tell us it’s about our lifestyles or our behaviour but do something about our environment so that it’s easier for us to live healthier and longer.

Premature Deaths from Cardiovascular Disease are significantly higher in Liverpool City Region – 80% could be avoided through behaviour change:

Deaths from Cardiovascular Disease

DSRs = Directly Age-Standardised Rates

But for behaviour change to happen we need less emphasis on the individual more on the environment

  • We are surrounded by junk food and bombarded with messages to buy sugary drinks and processed food
  • It’s sometimes cheaper to buy alcohol than bottled water
  • Our traffic systems are built around cars when bicycles are the environmentally healthy choice
  • And a growing habit-forming behaviour that is leading to public health concerns
More controls on junk food marketing to kids

More controls on junk food marketing to kids

A Labour Government should close existing loopholes to restrict children’s exposure to junk food marketing across all the media they are exposed to. This should include updating current broadcast regulations with a 9pm watershed on advertising of food and drinks high in fat, sugar and salt to protect children during family viewing time and taking action to ensure online restrictions apply to all content watched by children. In addition rules should be extended to cover sponsorship of sports and family attractions and marketing communications in schools”  – Obesity Health Alliance Manifesto, April 2017. Emphasis my own.

Cheap lager

Minimum Unit Price of Alcohol. Ok in Scotland and Wales. How about the UK?

  • Low prices lead to increased alcohol consumption and alcohol-related harms
  • The cheapest products are favoured by the heaviest drinkers
  • A minimum unit price will reduce consumption and harms and will do this more effectively and more fairly by targeting the heaviest drinkers

Congested street

Have things changed from the ‘90s? This is Liverpool

People will only turn to cycling in great numbers when there is a significant investment in safe infrastructure.  

“Doctors should care about cycling, as it’s one of the best preventive health interventions we have. Active commuting, including cycling, is associated with reductions in mortality, cardiovascular disease, and cancer. Body mass index and the percentage of body fat are lower in active commuters …

And it’s not just the individual cyclist who benefits. Car drivers who switch to a bike will reduce air pollution”.

Dr Margaret McCartney, BMJ, October 2017

Go by bike

Cycle commuting is associated with a lower risk of CVD, cancer, and all cause mortality. Walking commuting was associated with a lower risk of CVD independent of major measured confounding factors.

Gambling – How has it got to this?

Gambling sponsors football

Gambling is a Public Health Issue

  • It was the Labour Party who deregulated gambling in 2005. It has damaged the health of the nation
  • It’s a problem that goes beyond simply dealing with Fixed-Odds Betting Terminals
  • The Gambling Commission estimate that the number of British adults with gambling problems is in excess of 400,000 with a further two million at risk of significant health and social problems
  • Let’s ban shirt sponsorship by gambling companies in football
  • And let’s have a radical overhaul of gambling regulation
Benjamin Franklin 1706-1790

Benjamin Franklin 1706-1790

Prevention demonstrates a substantial RETURN ON INVESTMENT – most published health interventions are substantially COST-SAVING

Public Health Priorities for Labour – How Far Do You Dare To Reach?

  1. Change the environment so the default option is healthier.  Lay off on the victim blaming!
  2. We must do more to prevent junk food marketing to our kids which in turn fuels childhood obesity
  3. The evidence is there for Minimum Unit Pricing for Alcohol. Please act
  4. Cycling can and should be for everyone but there must be significant  investment outside London
  5. There should be a radical overhaul of gambling regulation

This was presented at our conference Public Health Priorities for Labour

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Physical inactivity

41% of the adult population in England are insufficiently active (HSE 2012: 35% men, 46% women)

Obesity trends

Diabetes

Walking and cycling:

  • can provide the same health benefits as sports or other exercise
  • can increase cardiorespiratory fitness
  • to work is as effective as a training programme and can fulfil the recommendations for physical activity.
  • and it’s good for the local economy

Car commuters in Adelaide, Australia gained more weight over a 4 year study than non-car commuters.  The effect was particularly pronounced when comparing those who had sufficient leisure time

  • Switching from car to active travel or public transport: Body Mass Index fell by 0.32kg/m2 (95% Confidence Interval 0.05-0.60)
  • Switching from car to active travel: Body Mass Index fell by 0.45kg/m2 (95% Confidence Interval 0.11-0.78)
  • Switching from active travel or public transport to car: Body Mass Index rose by 0.34kg/m2 (95% Confidence Interval 0.05-0.64)

The benefits of walking and cycling include:

  • Activity
  • Age-independent
  • Affordable
  • Access
  • Air quality
  • Flexible
  • Mental health
  • Less sick leave
  • Longevity

Health impacts of Air Pollution include:

  • Asthma
  • Other respiratory disease
  • Heart attacks
  • Stroke
  • Lung cancer
  • Obesity
  • Neuro-developmental disorders
  • Neuro-degenerative diseases

There are 40,000 deaths per year in UK from air pollution and costs in the  UK exceeds £20 billion a year. More vulnerable populations disproportionately in poorer communities, the old, the young and those with existing circulatory or respiratory disease.  Poorer communities are disproportionately exposed to air pollution.

Transport should be about shifting people or freight, not cars or lorries.

  • Motor vehicles are the only increasing source of air pollutant emissions in the UK
  • Transport benefits accrue more to car users
  • Harms from motor vehicles accrue more to poorer, more deprived communities

The policy response should be to reduce car use and spatial planning that does not assume or encourage car use

  • ↑ Active travel – ↑ physical activity
  • ↓ Emissions of pollutants
  • Serious injuries
  • Transport inequalities

Save our cyclists

The media – and doctors – notice injured cyclists. They don’t recognise the dangers of not cycling.

 

Fatalities by mode - younger

Fatalities by travel mode

Fatalities per billion km by mode and sex,aged 17-69

The actual risk for cycling (Figures for England 2010-2):

Risk of death for males (20.8 per billion kilometres)

  • 1 per 48,000,000 kilometres cycled
  • Individual risk: one fatality every 32,000 years (assuming typical cyclist rides about 1,500km pa)

Risk of death for females (16.9 per billionn kilometres)

  • 1 per 59,000,000 kilometres cycled
  • Individual risk: one fatality every 39,000 years

The Transport Planning Heirarchy

active travel

A default national speed limit of 20 mph on residential streets would make a lot of difference to fatalities:

  • Reduces risk of collision
  • Reduces injury/fatality consequences if collision occurs
  • Reduces fear of traffic
  • Makes streets more pleasant places for social use, including children’s play
  • Encourages walking & cycling

Fatality risk related to speed

So far

Local Authorities covering 13.5 million people in UK have implemented it locally

National legislation is:

  • Much cheaper
  • Changes the accepted norm more quickly – affecting drivers’ behaviour
  • Smoother driving, reduces pollution
  • Improves police enforcement
  • Adds less than a minute to most journeys
Crossing the road

Increase crossing times on signalised crossings

Walking speed

Walking speed by age

Walking speed by age: Most older pedestrians are unable to cross the road in time

HSE 2005 timed walk data showed road crossings are set too quickly for more than 3 in 4 older people and  children, parents, those in wheelchairs or with other impairments, with luggage, etc.

Expenditure on transport and active travel

We should invest in active travel.

Public Health England:

“Health-promoting transport systems are pro-business and support economic prosperity …enable optimal travel to work with less congestion, collisions, pollution, and.. support a healthier workforce.”

  • Set a legal minimum % of national & local transport budgets to be spent on active travel (eg 5%? 10%?)
  • Better quality pedestrian environment
  • More, better cycling infrastructure (especially junctions)

Invest in Public Transport instead of subsidising car travel

  • Building roads
  • Costs to society from car use (externalities)
  • Benefits (social & economic) of public transport
  • Easier & cheaper to travel by public transport
  • Average cost vs marginal cost for car use
  • Reverse the Beeching cuts to reinstate local rail services
  • Bus regulation to enable joined-up thinking and journeys that work
  • Faster replacement to Euro VI standards
  • Retrofitting existing buses & coaches

Funded by

  • Not building /widening major new roads
  • Road charging (polluter pays) &/or taxation on fuel, reflecting costs to society (NOT scrapping fuel duty rises for cars!)

Faculty of Public Health. Local action to mitigate the health impacts of cars.

5 Priorities for national government:

  1. Default 20mph speed limit nationally for residential streets
  2. Better crossing facilities – more crossings, more time
  3. Invest in active travel
  4. Invest in public transport
  5. Enforcement of existing laws & rules

This was presented at our conference Public Health Priorities for Labour

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It is always an absolute pleasure to speak at a SHA event – this being my third in the year that I have been Labour’s Shadow Minister for Public Health.

It is wonderful to be with so many like-minded people who are committed to improving people’s health and ensuring that prevention is a key cornerstone of our approach to public policy.  I know you have an incredibly packed agenda with many excellent speakers, so I won’t be keeping you for too long. But in my contribution to today’s discussions I want to set out Labour’s approach to public health and how all of you can help shape and contribute to the policy development as we move forward in this Parliament, and to the next General Election – whenever that may be.

That said, Labour are ready to take on the task of addressing the challenges we see when it comes to the public’s health. I can commit to you today that whenever the public give us the opportunity to govern, Labour will be ready to get on with the task at hand of reversing the damage inflicted after seven years of Tory rule.

For Labour, our clear aim is to champion better public health services across the country which tackle the entrenched health inequalities that have been all too often ignored, tackling the permeation of ill-health that cripples our communities and ensuring our NHS has the right level of funding and resources so it is fighting fit for the future. Under the Tories all of this has been ignored and failed. It cannot go on any longer.

Specifically, when it comes to public health, I have identified what I believe to be a “public health crisis”. This is not about scaremongering or blustering; it is seeing what the Tories have done to our NHS and wider health services and having the understanding that their actions have consequences which put our nation’s health in jeopardy. We all know the facts – by 2021, £800 million will have been siphoned away from public health services and this has had an unimaginable impact on services in our local communities which have stalled the improvement of health we so desperately need.

It isn’t just Labour who have recognised these concerns, but the likes of The King’s Fund, who earlier this year, analysed DCLG data on local spending priorities for public health and found that the prognosis was not good. Their analysis identified that local authorities would be spending on average 5% less on public health initiatives than in 2014 with some of the worst hit services being sexual health promotion and prevention along with wider tobacco control which both see devastating cuts of more than 30%.

The King’s Funds’ conclusion is one that I completely agree with. They said:

“… there is little doubt that we are now entering the realms of real reductions in public health services. This is a direct result of the reduced priority that central government gives to public health.”

The idea of reduced priority isn’t one without basis. If we look at NHS England’s Five Year Forward View update report compared to the document published in 2014, public health has seen a clear downgrade from “a radical upgrade” to one deemed to be no more than an efficiency saving exercise in the 10-point efficiency plan. Whilst efficiencies can always be found to improve outcomes and results, they categorically should never be done to the detriment of our health.

Since 2013, when public health was moved from central government to local authorities, it was welcome to see a more localised approach to addressing health needs – as we all too often know that health inequalities can be local and must be addressed by those who know their communities the best rather than faceless civil servants at their Whitehall desks. Yet as the planning, commissioning and procurement of these services was devolved they were met with eye-watering cuts which left them struggling to ensure the new responsibilities they had acquired could be used effectively. The icing on the cake, for those who believe passionately that improving public health should be done at a local level, was scrapped away when central government laid down these short-sighted cuts. This has meant that services have had to fight to survive and maintain the standards that the public have come to expect, which in turn has led to the money needed to oil the wheels of innovation at a local level has not materialised.

It is always important that innovation sits at the heart of public health so we can meet the health challenges of the day and ensure that we continue to move towards a society that is healthier and happier.

Whilst the local level has seen serious problems arise because of the Tories’ failures, there have also been concerns about action at a national population level too. It is safe to say that delay, decisiveness and joining of the dots are lacking when it comes to national policy by Tory ministers.

We have seen an 18-month delayed Tobacco Control Plan finally published which failed to recognise that to provide the vision of smoke-free society set out in the Plan, that the Government must put their money where their mouth is to see it succeed. The same can be said of the Home Office’s Drugs Strategy which failed to move on from its 2010 predecessor and ignored the significantly reduced funding envelope for prevention and treatment services we now have. We also saw the PrEP Impact Trial continually delayed after the evidence has been abundantly clear that providing PrEP can revolutionise our approach to halting the spread of HIV in society. Then there is the failure to address burgeoning issues such as lung diseases with what can only be described as disdain by ministers even considering the idea of a lung diseases strategy which could help co-ordinate action to improve outcomes for those blighted by these diseases, especially those in our most deprived communities.

The most perfect example of these failures by ministers was the Childhood Obesity Plan – published over a year ago now. Though measures announced in the Plan two summers ago were, of course, to be welcomed and it is pleasing to see steady progress has been made when the Government published their update this summer, the Plan and the progress made have left us wanting. We all know that obesity is one of the most burgeoning public health crisis facing our country right now and this Government have done the bare minimum so they can be seen as if they are acting on these worries. Labour won’t let this continue and we set out quite clearly how we would do this in our manifesto in June of this year with a radical approach to childhood health issues.

However, it is not only health issues specific to the brief which I shadow that this Government are failing on, but a whole host of policies which are damaging when it comes to our nation’s health. The clear and most pronounced of these is: the growing prevalence of poverty in our society. Poverty is not an inevitability of society but is in fact an inevitability of a failed society. Through-out my parliamentary career, I have ensured that poverty is one of the key issues that I work on – may this have been through education or health matters. It is what drives me in my work in Parliament as it is a damning indictment of any society to see poverty become so normalised that it is left to be ignored, especially in one of the richest countries in the world. And it is what will drive me if I am ever honoured with the chance to be a minister in Government. Poverty is a multi-faceted issue and realistically one fix will not address all of the causes of poverty, but the fact of the matter is, austerity is exacerbating the problems of poverty we see in our society. Instead of putting their heads in the sand, it is high time that ministers got to task and addressed these issues head on. Poverty has untold consequences on our society – may this be on education, life opportunities or on our health.

These matters cannot be ignored much longer and it is important that governments put the health of our nation first and to do that health must be considered in every action that is taken by a Government. What I have set out is a sorry state of affairs which we find ourselves in due to the crippling policies of the Tories, but Labour is up to the task of reversing them.

We have heard it said often since the snap General Election in June, but Labour is a government-in-waiting and Labour’s Shadow Health team of myself, Jon as our Secretary of State and Barbara, Justin and Julie, are ready to work tirelessly to improving our nation’s health. We have a track record on this. Take our June manifesto, where we set out in a comprehensive fashion a radical programme on public health and wider health and social care services. I, for one, was incredibly proud of what we offered to the country. I may be a bit biased here but we offered hope and a true vision on what government should be doing around health. But, as I said at the outset of my speech, we must continue to look forward – especially with another General Election forever looming over us with this shambolic government in office.

That is why I welcome these opportunities to meet with you all and speak to you about our priorities as a Labour Party. And about what you believe a future Labour Government should prioritise when it comes to our health policy. We have a lot to sort out, so there will be many competing priorities if we are to get into office but I want you to know that I will continue to champion an improved preventative health service and work towards our ambition to be the healthiest society we have ever seen. I can only do that with your support and guidance, but I know for sure that together we can achieve this ambition that I lay before us today.

This was presented at our conference Public Health Priorities for Labour

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