Feeds:
Posts
Comments

Archive for the ‘Obesity’ Category

by Dr Geraint Lewis

For the past eight years, I have had the sometimes-dubious pleasure of living in London’s King’s Cross neighbourhood.  Being so close to the centre of the city, I do my best to cycle as often as I can around town. However, my repertoire of safe cycle routes is rather limited, and I dread straying too far away from my familiar routes and ending up somewhere where I have to battle my way home through the frenzied London traffic. The result is that I cycle less often, and less far than I would like to.

To be fair, these days there is a wealth of websites and apps that could help me navigate safely around London by bike.  The trouble, though, is that the safe bike routes themselves are just too complicated.

Take an example. Let’s say I wanted to cycle from my home in King’s Cross to St. Thomas’s hospital near Waterloo.  Although I know the walking route I would take to get there, I have no idea how reach the hospital safely by bike.  Go to the Transport for London  (TfL) website and it suggests a route that involves no fewer than 57 stages—as compared with two stages for the same journey by tube (Piccadilly line to Leicester Square, then the Northern line to Waterloo).

Indeed, London’s cycle network is so complicated that TfL appears incapable of displaying it as a complete map on its website.  Instead cyclists must order 14 paper maps to cover the whole city, plus a separate PDF for each of the new cycle superhighways that are currently being built.  Even where individuals have gallantly tried to produce simplified bike maps of London, the end result still bears too much resemblance to a plate of spaghetti.

Other cities have had a go at creating much simpler cycle maps aimed at encouraging more people to cycle. In Edinburgh, for example, Mark Sydenham and Martin Baillie have developed a tube map for bikes.  But the reality is that Londoners, like the citizens of many large cities, actually use the public transport network as their “mental map” for getting around their city.

The idea that Tim Miller and I suggested is that planners should build a bike network that recreates this mental map we are all so familiar with.  London’s bike network would directly resemble the tube map; Newcastle’s would follow the metro map, and so on.  In the jargon, what we are calling for are cycle networks that are “homeomorphic” or “topologically equivalent” to their public transport network. So in London, the cycle network we would like to see built would join up every tube station using analogous bike lanes to the tube lines – sharing the same names, colour codes and destinations as the tube lines.

So in this new world, my journey from King’s Cross to St. Thomas’s would simply involve taking the “Piccadilly bike lane” to Leicester Square, and turning left to go down the “Northern bike lane” to Waterloo.

What would be the costs and benefits of this proposal? Clearly, to build a network of safe cycle routes would take a large, sustained investment.  It would require building tens of kilometres of off-road bike lanes and closing off a considerable number of streets to through vehicular traffic.

However, the London tube map is a fixed asset that will be with us for generations to come, so this expenditure should be viewed as a very long-term investment. Just as with the tube network’s 150 year history, we would need to start small and build up the cycle network slowly, bike lane by bike lane and tube stop by tube stop.

From a public health perspective, I suspect the benefits of this proposed scheme would be at least fivefold.  First, it would encourage more people, including visitors to the city, to make longer journeys across town because they would now have more confidence that they could get to where they were going and be able to find their way back in one piece.  Second, it could reduce fatalities if more cyclists used off-road cycle lanes and quiet roads that had been closed to through vehicular traffic.

Third, it would reduce the city’s carbon footprint. Fourth, it would encourage cross-modal journeys because the cycle network and the rail network would now be inextricably linked. But finally, and rather sneakily, we might be able to increase journey distances from point A to point B by designing cycle routes between tube stations that were slightly more circuitous than were strictly necessary.

Read Full Post »

Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners.  Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost.  Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the   hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are.  Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base.  But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery.  This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

Read Full Post »

By Alan Maryon-Davis

Health Secretary Andrew Lansley wants to encourage people to eat healthily, drink sensibly, stop smoking and get more active without lecturing or hectoring them. People don’t like being told what to do or not do – least of all by the Government – so Lansley says we should provide them with information and incentives and let them choose for themselves – nudging rather than nannying. Hence the Great Change4Life Swapathon with its supermarket discount vouchers for healthy options. Lots of carrots, no sticks.

There’s also much nudging behind Lansley’s Responsibility Deal with the food, drink and fitness industries. Double nudging – Lansley nudging them to nudge the public. Industry will “pledge” to provide information and incentives encouraging healthier choices.

So where’s the fudge? In return for industry cooperation (and cash) Lansley has said he’ll go easy on mandatory regulations around such things as marketing, labelling, availability and pricing. To be fair, he doesn’t rule these threats out completely. He talks about the Nuffield Ladder of Interventions, with the least intrusive (information, education and incentives) at the bottom and the most intrusive (regulation and legislation) at the top. But he’s made it clear he doesn’t want to climb that ladder unless he absolutely has to. It wouldn’t fit his political philosophy.

So there’s a big fudge around how he’ll monitor adherence to voluntary approaches, assess progress and judge when to bring in mandatory controls. The food and drink industries are notoriously slippery, evasive and foot-dragging – just look at labelling and marketing. Meanwhile the health lobby is going along with the Responsibility Deal in the hope that things might be different this time – well aware they risk being be-smudged as part of the fudge.

I’d like to see a solid pledge by the Government to regulate or legislate if voluntary approaches fail and to be crystal clear about how and when such judgements will be made. Without an explicit commitment to use force if necessary, the deal will be seen as no more than a charade letting Big Business off the hook.

Read Full Post »

Baroness Tanni Grey-Thompson talks to FPH’s Suvi Kingsley about the Olympic bid and legacy, and her top tips for parents struggling to get their kids moving.

Read Full Post »

Baroness Tanni Grey-Thompson gives the second keynote speech at the Faculty of Public Health Conference on Wednesday 7 July.

Read Full Post »

Eleven time Paralympian gold medallist Baroness Tanni Grey-Thompson spoke to the UK FPH conference today (7 July) about the importance of the 2012 Olympics in encouraging physical activity, particularly amongst women and children.

She called for the 2012 budget to be protected from cuts, underlining the potential cost savings to the NHS if it can be used to promote and support people to exercise more often. Inactivity costs the economy an estimated £8.2 billion a year in England, and Grey-Thompson challenged the public health community to find more innovative ways of encouraging participation in sports and exercise.

Physical activity contributes to the prevention and management of conditions including coronary heart disease, diabetes, cancer, mental ill health and obesity. Grey-Thompson said that “Promoting physical activity is integral to the preventative agenda. In a time when budgets are being cut across all public services, the NHS and wider economy cannot continue to bear the increasing financial burden of preventable conditions.”

Read Full Post »

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.

Read Full Post »

« Newer Posts - Older Posts »