Better Health For All

In October 2017, I was honoured to present the Royal College of Physicians of London Milroy lecture.

In the lecture I described the potential benefits of four dividends for better health: 

The Peace Dividend, the idea of ‘swords to ploughshares’- diverting military technology for peaceful, socially-useful purposes; an idea which took off with the end of the Cold War.

The Health Dividend, first described in three local Sandwell studies of anti-health vested industries and which came to be applied to the corporate citizenship role of health services.

The Inclusion Dividend, whereby design for disability in industrial and technological processes can produce better solutions for independent living for people with disabilities, but also for everyone.

The Green Dividend– where, for the protection of the planet, and for our health, we must look to the most environmentally-friendly use of energy and natural resources.

After the Cold War, politicians talked about the ‘peace dividend’ – the benefit that would arise from diverting investment, material resources, human intellect, and endeavour in war, towards peaceful, socially beneficial use. From 1986-1996, I was involved in researching Coventry defence industries and advocated alternative applications of the technologies for socially and environmentally useful purposes.

 I applied the same principles in my work as Director of Public Health in Sandwell. There were industries with a vested interest in making people ill, which could diversify into less-unhealthy production and services, thereby delivering a health dividend. We researched local tobacco retail, the food industry and alcohol trade and proposed new models of production and services for food and alcohol.  

Recognising human ingenuity and a drive for socially useful production led me to argue for design for independent living and for technology, which limited the impact of disability and promoted inclusion.  Applying technology to the needs of people with specific handicaps can generate solutions, which are of benefit to the wider community. This we called ‘the inclusion dividend’.

In the era of global warming and climate chaos, a new green industrial revolution is needed, capable of delivering sufficient green energy to supply the world. It requires us to harness technological and socially useful production- for energy-saving devices, for renewable energy production, for energy storage, for energy generating buildings and for transport systems.  In so doing, we can create jobs, create healthier living standards, and protect the global environment- the green dividend.

My lecture considered the relevant issues of diversifying health-damaging industry and harm reduction in issues which affect us today: Non-lethal weapons? The safer cigarette? Healthier eating? The non-polluting car?

Effort to engage with ‘Big’ business to find healthier alternatives is difficult and is fraught with pitfalls and dangers. Unhealthy big business will continue to profit from the misery they inflict on millions, and will continue to need regulation, taxation, and controls. “BIG” businesses will throw a smoke screen on the extent of their concerns for health and their efforts to create healthier alternatives, and we will be deflected and distracted. But dialogue, and challenge, and real diversification of industry is needed more than ever.

You can download the slides from the lecture here.

Read the full lecture transcript here.

And watch a recording of the lecture here.

Professor John Middleton
Past-President of the Faculty of Public Health

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Sometimes I think politicians must be smarter than they seem when baying during Prime Minister’s Questions.  I’ve spent the past couple years or so discussing pension reform with relevant actors within the social policy process (academics; civil servants; employers; politicians; professions; think tanks; trade unions) without realising that UK Members of Parliament had built an escape clause into the legislation.  As Therese Coffey (Secretary of State for Work & Pensions) explained to the House of Commons last 4^th December: Section 27 of the 2014 Pension Act demands a second Government Review of the State Pension Age by May 2023, for which already she has commissioned independent reports from Martin Clarke (Government Actuary) and Lucy Neville-Rolfe (Peer of the Realm). 

If you look at the ONS Longitudinal Study, it is clear that at each decennial census since 1971 the proportion of women in their 50s who describe themselves in labour market terms (paid employment; unemployed; permanently sick; retired) has increased steadily, so it is reasonable that women and men should have the same State Pension Age, although why the gender difference should have been equalised up (first to age 65 years, now 66 years and soon 67 years, then 68 years) rather than down (to age 60 years), is less obvious.          

The official reason is the increase in life expectancy during recent decades.  One problem with this explanation is that the rate of increase in life expectancy now appears to have stalled and that, if and when it resumes, it is likely to lack its previous vigour.  The bigger problem is that being alive is not the same thing as being capable of holding down a job; hence the need to think in terms of healthy life expectancy.  Here the devil is in the detail and Lucy Neville-Rolfe has been tasked with adjudicating.  John Cridland’s previous review opted to measure the healthy part of healthy life expectancy in terms of self-assessed health, although many consider that the absence of physical or mental disability would have been more appropriate.    

I am one among the number who would prefer to see the State Pension Age linked to disability-free life expectancy, but my concerns are not limited to this technical issue.  I am also part of an informal group of public health specialists who wish to draw attention to the possible unintended consequences of raising the State Pension Age and contribute to discussion of how to mitigate these.        

Our concerns are that extending work-life may: (1) worsen the health of those with pre-existing illnesses; (2) overwhelm sparse occupational health and over-stretched general practitioner services; (3) hinder informal caring at a time when the need for it is projected to increase; (4) deter the volunteering which supports the NHS and the many charities upon which public health depends; (5) trigger overt disease in those with asymptomatic pathology or previous good health.  Our report, detailing each of these items, can be downloaded free here.       

We suggest that our concerns could be mitigated by [1] commissioning two pieces of research to establish (a) evidence-based triage criteria to guide occupational health & general practitioner services in deciding which older employees are most at risk; (b) whether extending working lives will increase the mortality risk of older employees in the most disadvantaged occupations. And [2] two changes to administrative regulations to accept (a) greater flexibility in the age range 60-68 years, to accommodate patterns of relapse and remission in chronic disease; (b) that paid employment is not the only type of socially necessary labour at these ages, with informal caring and volunteering as appropriate and legitimate alternatives.

Finally, there are issues of financial loss and workfare.  Many of those now working until age 66 years spent most of their life paying their National Insurance contributions when its regulations increased the size of their State Old Age Pension in line with any years worked beyond the state pension age; the increase in the state pension age removed this entitlement, at a cost per person of up to £300 per month for life which, for Pension Credit recipients, could be the difference between living with or without the older person’s Minimum Income for Healthy Living.  To add insult to injury, now these same individuals find themselves subject to conditionality (fitness for work testing) and sanctioning (benefit cuts), which those who saw the Dispatches report on the subject (Channel 4, 17^th December 2021) will find it hard to believe that MPs intended when they voted through the 2014 Act.    

David Blane
Professor Emeritus of Imperial College London

CORRECTION WITH APOLOGIES

“all three of whom, it may be relevant to note, will be entitled to solid gold pensions when they retire (non-contributory, defined benefit, final salary).” – removed from final line of Paragraph One.

Civil service and parliamentary pensions are contributory (at 6% of salary) and paid on the basis of career average salary; inflation-indexed defined benefits remain.  

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