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Archive for the ‘Health Inequalities’ Category

Afternoon parallel session at the Faculty of Public Health annual conference, on Wednesday 7 July.

Chaired by Alastair McLellan, Editor of the HSJ, and panel members Martin McKee, Professor of European Public Health at London School of Hygiene and Tropical Medicine, Michael Hagen, Merseyside Fire and Rescue Service, Stephen Hewitt, Specialist Professional Planner at Bristol City Council and Ed Cox, Director at IPPR North.

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Parallel Session A (c) at the Faculty of Public Health annual conference, Wednesday 7 July.

Chaired by Rachael Jolley (FPH) and with panel members Chris Bentley (Head of Health Inequalities NST, Department of Health), Peter Kellner (President, YouGov), Samantha Callan (Chairman of Residence, Centre for Social Justice).

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19 June 2010

In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.

Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.

But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.

He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.

Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.

Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.

The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.

But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.

As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.

What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.

Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.

This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.

As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.

As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.

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As expected, all three major political parties have this week made strong references to public, or, as they most commonly term it, preventive health in their election manifestos.

Ahead of the General Election on 6 May, the Conservative party have, at least superficially, made the most explicit commitment, with their pledge to re-title the signs outside Richmond House “The Department for Public Health”. As we already learnt in their draft manifesto back in January, they intend to rechannel public health funding to the most deprived areas, offering a financial “premium” to target health inequalities. Confusion reigns as to how this might be implemented, and the manifesto in general is long on the whats, but short on the hows, but the proposals are certainly attractively packaged, at least for the floating voter.

The present incumbents have of course to defend their record, as well as identify areas where they could do better. Labour face the accusation, made in the Tory manifesto, that inequality has increased on their watch. An interesting spin on this was printed by the Institute of Fiscal Studies, but Labour’s manifesto is relatively weak on how they would further level the playing field. The author of the Labour manifesto, Ed Miliband had previously trailed the idea of universal free school meals, something that FPH had also touted in our manifesto. This pledge is somewhat toned down in the manifesto proper, instead promising to “trial free school meals for all primary school children in pilot areas across the country … [to] thoroughly test the case for universal free school meals, with the results available by autumn 2011”.

Most commentators agree that the NHS has improved under Labour, (at least enough for the Conservative party to want to claim themselves to be the rightful heirs of Bevan’s legacy) but their commitment to the preventive agenda is vague at best. Citing their current (and, in some quarters, heavily criticised) Change4Life social marketing campaign, and the smoking ban as evidence for the defence is fine, but where are the plans to make a healthy “future fair for all”?

The Liberal Democrats, with their eminently sensible and intelligent spokesperson Norman Lamb, possibly have the most tangible pledges for the nation’s health. The cynic might of course argue that they can afford to make such idealistic and resource-intensive promises, unlikely as they are to assume the reigns of power. Nonetheless, persuading a party to nail its colours to the mast of minimum alcohol pricing is no mean feat, particularly when their colleagues north of the border are more reticent to declare themselves. The Lib Dems also follow the Conservative’s lead in linking financial incentives to addressing inequalities, “linking payments to health boards (as they would rename Primary Care Trusts) and General Practitioners more directly to prevention measures”. Lamb has talked previously about what essentially amounts to a beefed-up Quality and Outcomes Framework (QOF), paying GPs for achievements rather than measurements.

A curate’s egg for public health then from all the parties; whichever the colour of the incoming government, they still have work to do to clarify how they will improve the nation’s health, particularly in financially straitened times.

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The Faculty of Public Health today publishes our joint manifesto on public health, alongside the Royal Society of Public Health. 12 Steps to Better Public Health offers a dozen practical recommendations that, if adopted by the next government, will improve the UK’s health and well-being for the new decade.

The joint public health manifesto calls for:

  1. A minimum price of 50p per unit of alcohol sold
  2. No junk food advertising in pre-watershed television
  3. Ban smoking in cars with children
  4. Chlamydia screening for university and college freshers
  5. 20 mph limit in built up areas
  6. A dedicated school nurse for every secondary school
  7. 25% increase in cycle lanes and cycle racks by 2015
  8. Compulsory and standardised front-of-pack labelling for all pre-packaged food
  9. Olympic legacy to include commitment to expand and upgrade school sports facilities and playing fields across the UK
  10. Introduce presumed consent for organ donation
  11. Free school meals for all children under 16
  12. Stop the use of transfats

The full manifesto is available to read here, and the front-page Guardian story, with an accompanying podcast from our President Alan Maryon-Davis, is available to read here.

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“A Stalinist NHS quango” is just one example of the kind of newspaper coverage that the National Institute for Health and Clinical Excellence (NICE) has been hit with according to the Guardian Columnist Polly Toynbee“Notorious for denying life-saving drugs to terminally-ill NHS patients” was another, hardly more measured, journalistic description Toynbee chose to quote in her opening remarks at this year’s NICE Conference.

But behind these often negative headlines, NICE has been quietly issuing high-quality guidance that has acted as a beacon for a number of public health initiatives across England.  The hard work that has been going on in the background in consultation with clinicians, public health experts and, of course, patients, was palpable at the conference sessions.

“Shared Learning: implementing guidance promoting health and wellbeing” plenary highlighted some of the outstanding work that has been making a real difference in local communities around the country.

The first of these, led by Dr Peter Brambleby, Director of Public Health at NHS North Yorkshire and York, looked at the impact that creating close working relationships with both the PCT and the local Council has had on his community. Dr Brambleby stated the case for evidence-based commissioning, breaking down the word to illustrate what he means: co-mission-ing. The ‘co’ reminds that this is collaborative, the ‘mission’ reminds us that we are working together for a common purpose (improving the public’s health), and the ‘ing’ reminds us that this is a verb, an active, ongoing process.

The next two offered more practical examples of public health interventions making a difference in their local communities. Caryn Hall, a Consultant in Public Health at NHS Gloucestershire, outlined the work that they were undertaking with town planners to ensure that built environments are designed to encourage physical activity, helping to tackle the growing obesity problem. Julia Olijnyk, of Addaction Staffordshire, presented her project, a needle and syringe exchange programme for drug addicts in Stafford. She provided real-life illustrations of the helping hand that NICE guidance has provided in terms of engaging pharmacy staff in the project, resulting in positive outcomes and greater engagement with service users.

All three projects were shortlisted in the ‘Health and Wellbeing Category’ of the NICE Shared Learning Awards. Ultimately, the Addaction Staffordshire’s needle and syringe exchange programme triumphed, but all are excellent examples of public health in practice.

“Innovation and Value” was the overarching theme of the 2009 NICE Conference and away from the headlines, these three projects demonstrated those qualities admirably.

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By Dr Alex Gatherer

Consider some of the facts relating to prison health.  The majority of prisoners, some 80% or so, have some form of mental ill health, and between 5-10% have serious mental illness, which requires specialist care in suitable facilities.

Furthermore, in any community, the local prison at any one time will hold a disproportionately high number of non-nationals and minority ethnic groups, of people positive to HIV and Hep C, of people with educational and social skills deficiencies, of those addicted to some form of substance addiction, of those with serious communicable diseases and of those previously hard-to-reach in our cities and towns.

In most countries, including our own, this high needs group will be detained in old premises with inadequate facilities for meaningful activity and recreation and often in overcrowded conditions.

And the majority of prisoners will be out of prison and back in their home environments on the streets in our communities often after only a short time.

‘Statistical compassion’ is one of the unmentioned skills required of top quality public health practitioners.  We must be able to look behind the statistics and see the suffering, the unmet needs and the social injustices amongst the individuals who make up the overall figures that are so central to the reports we write.  Without ‘statistical compassion’, how can we make sure that we take into account, in everything we do, those who are in greatest need?

Public health has a choice. We could ignore the above, as we did for many years and waste any opportunities to help a vulnerable high risk group. Or we could realise that it is in the interests of public health as a whole to prevent our prisons from being focal points of disease.

We could also realise that the right to health applies to all.

  • Dr Alex Gatherer is Fellow of the Faculty of Public Health. In November 2009 he was awarded the American Public Health Association’s Presidential Citation for his work in improving health in European prisons.

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