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Archive for the ‘PH Spending’ Category

By Dr Nadeem Hasan

The importance of effective advocacy to achieving public health goals cannot be overstated.
Every day policies and regulations that affect health outcomes for better or worse are put on the agenda and kept off the agenda; discussed and debated; approved and rejected.

Many, if not most of these relate primarily to non-health sectors, such as food and beverages, energy and infrastructure, and alcohol and tobacco. But their impact on health outcomes is very real: all the stop-smoking programmes in the world can’t match the impact of the ban on advertising and smoking in public places on smoking prevalence; and there’s no amount of spending on childhood obesity programmes that can make up for the regulatory vacuum in this area.

Looking more broadly, policy decisions that affect income inequality, carbon emissions, and military action all have serious consequences for health across the world.

If we’re serious about prevention, we need to be serious about advocacy.
Where profits can be affected (almost everywhere), industry lobbyists seek to influence the regulatory environment in their favour. And they are very good at it. In principle, this is quite right – those affected by policy and regulatory shifts should indeed be able to make representations and provide additional evidence to support the decision-making process – and this includes relevant industry actors.
Representing the interests of everybody else is where advocacy organisations come in – acting as sort of ‘civil society lobbyists’ to balance out the discussion – advocating on behalf of the health, wellbeing, and broader concerns of the general population. Notably, this isn’t always an ‘us vs. them’ relationship: health insurance companies are routinely allies on advocating for lower drug prices; and renewable energy companies are more than happy to work with advocacy organisations on climate change regulation.

Put this way, it might sound like a fair playing field, with decision-makers receiving submissions from a range of groups and making balanced decisions to maximise the benefits to all parties. The reality of course is quite different, and much, much messier.
In 2014, there were an estimated 30,000 industry lobbyists in Brussels alone, falling just short of the 31,000 employees for the whole European Commission.

Civil society pockets are not deep enough to come close to matching this (or the salaries of lobbyists), and civil society advocacy and pressure groups are few and far between. Transparency falls short of the ideal, and the revolving door between policy-making and industry remains alive and well. Most recently the former President of the European Commission José Manuel Barroso was appointed Chairman of Goldman Sachs International, a move that has been widely criticised.
Advocacy organisations, then, have a difficult task – but one where even small successes can have far-reaching benefits for public health.
The European Public Health Alliance (EPHA), based in Brussels, is one such advocacy organisation. They bring together a range of health-related NGOs to advocate for better public health in Europe, working across five campaign areas: antimicrobial resistance; food, drink and agriculture; healthy economic policy; universal access and affordable medicines; and trade for health (and specifically the EU-US free trade agreement – TTIP – and the EU-Canada free trade agreement – CETA). Earlier this year, they hosted myself and another registrar in a pilot placement to understand health advocacy at the European level and to develop skills in this area.
So how to sum up the placement?
Invaluable. EPHA track the policy process for each one of their campaign areas and engage at every possible point. They attend every meeting at the European Parliament and the European Commission on these areas and make oral contributions at every opportunity; they submit comprehensive written responses to every relevant consultation; they engage on a daily basis with journalists to publicise their positions and build public support; they engage like-minded actors in the public, private, and not-for-profit sectors on a case-by-case basis to coordinate action; and they do all of this with just a handful of relatively young staff and interns.

They were very welcoming in bringing us into the whole process, allowing me to engage in every one of these steps – from writing position papers and consultation responses to making oral contributions at the European Commission and Parliament on their behalf.
Notably, EPHA also position themselves as an advocacy agency that actors from across the spectrum can engage with – in contrast to, for example, much more vocal organisations such as Greenpeace.

By way of example, the area that I was working on was TTIP. Whilst there are a raft of advocacy organisations across Europe (and the USA) that reject TTIP outright, EPHA’s

approach is to work through the whole agreement and advocate for the protection of public health on a section-by-section basis without rejecting the whole deal. With the European Commission politically committed to getting a deal, this makes EPHA one of the few organisations they can meaningfully engage with on this issue (though recent developments have called into question the likelihood of getting a deal in the near future).

This isn’t to say that their approach is ‘superior’ – every actor plays a particular role, with the more intransigent organisations key in shifting public opinion and providing the space for actors such as EPHA to engage in more balanced discussions. This means that they are invited to closed-door sessions with only a handful of actors, and have much more influence on the process than they otherwise would.
One of the challenges from a ‘public health professional’ perspective was that effective advocacy sometimes involves taking – shall we say – a less balanced view than we would normally as technical experts. From an ethical perspective, this raises a number of questions around whether the ends justify the means. I witnessed first-hand industry lobbyists making quite outrageous claims, including a rather undignified moment where I coughed up half my glass of water in a large auditorium at the European Commission when it was submitted that ‘alcohol is in no way an unhealthy commodity’ .

In a world where climate change denial is alive and well despite the most overwhelming evidence to the contrary, the ‘best’ approach to making our points is perhaps not so easy to discern.
And what of the relevance to the UK, particularly as we now start closing our doors to the EU in a bid to be a more open, global-facing country?
Whether or not the UK is a member, the EU remains a powerful actor that can influence policies related to public health both for its own citizens (which will still number ~450m after the UK leaves), and globally. As a close neighbour, EU regulations will have a strong bearing on public health in the UK too, and so engaging in advocacy at this level will continue to be an effective approach to improving UK public health.

This is true for everything from environmental regulations and air pollution, to pharmaceutical regulations and drug pricing and safety.
Within the UK, whilst it’s true that our policy-making process is not as amenable to advocacy as at the EU level (or remotely as civilised), effective advocacy still has huge potential to improve public health. We have not done well recently, with a watered-down childhood obesity strategy, no resistance to an unfunded ‘7-day’ NHS (that differs from the 7-day NHS that has existed since 1948 in some undefined way), and year-on-year increases in the use of food banks without any policy response (to name just three areas).

At the local level, there are a cornucopia of opportunities for advocacy to improve health, from influencing urban planning (fast food outlets close to schools, street design, cycling lanes) to advocacy around shifting public perceptions e.g. from opposing to welcoming refugees into local communities.
In this context, strengthening the advocacy skills of the UK public health workforce through engaging with and learning from experienced actors such as EPHA should be pursued with vigour – we can ill afford the alternative.

Dr Nadeem Hasan is a Specialty Registrar in Public Health

 

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by Paul Southon

  • Public Health Development Manager
  • UK Healthy Cities Network Local Coordinator

Welfare reform is a reality. Reviews of the likely health impacts suggest that they will be significant, are starting now and will last for a generation. (1) (2)

Work to quantify the financial implications for local areas shows that the financial impact will be disproportionately felt by the areas with the largest health inequalities. (3) There is also evidence that the impacts on already disadvantaged sections of communities – such as disabled people, black and minority ethnic groups and women – will be disproportionate. (4) (5)

All of this is happening at a time of major reductions in budgets and staffing across the public sector which limits the local ability to respond. This has been described as a perfect storm for local government. It will also have significant impacts across health services.

Over the longer term there is likely to be an increase in mental health problems, non-communicable diseases and related disabilities which will be felt across the health and social care system. Increasing poverty, especially child poverty, will have long term and generational impacts on child development, health outcomes and life expectancy.

GPs are reporting an increase in people with mental health problems. They are also reporting increasing numbers of requests for support with appeals against Work Capability Assessment decisions and the changes to disability benefits.

Currently the most visible part of the welfare reforms is the spare room subsidy or ‘bedroom tax’. Families on housing benefit who are defined as having extra bedrooms suffer a financial penalty. There is a severe shortage of available smaller properties for these families to move into. Their options are to move into the private rented sector, which may be more expensive, or stay where they are with a reduced income. Families are also moving to areas with lower rents, losing their social and support networks.

Councils are already reporting increases in rent arrears.(6)It is likely that this will lead to increased stress and family tensions, which could be exacerbated by the loss of social and support networks. A concern is that these families will resort to using alternative lenders, such as pay day loans, to cover shortfalls. One payday loan company has recently increased its typical APR to 5,835%.

For families experiencing poverty food becomes a major problem, both in access to enough food and in the quality of the food available. The rapid rise in food banks is testament to the difficulty families have in buying food. (7)

They also have to rely on the cheapest food which is often poor in nutrition and high in fats, including trans-fats. With the current food environment eating healthily is not a cheap option.

So, welfare reform is a reality. The evidence suggests that it is likely to have a major negative impact on public health and inequalities. It is now time to ask the key question: What can local areas do about it and what is the role of public health?

Much of the focus in councils has been on setting up the local systems to manage what were previously national benefit systems, the social and crisis fund payments and council tax benefits. Now these are operational the wider impacts of the reforms are being considered.

Many councils are mapping the local impact of welfare reforms to better understand the local challenges. (8) However, the scope to tackle these challenges at a local level is limited.

One of the stated aims of the welfare reforms is to encourage people into work. This is a laudable aim. Supporting someone into good quality work is a major public health win. The main way to reduce the numbers of people reliant on benefits will be to increase local employment.

However, increasing local employment is challenging in the areas where welfare reform will have the largest impact. Many of these areas have poor levels of educational attainment. Much of the available employment is low paid and insecure. A recent report estimates the local financial impact.

For example, Sandwell will lose around £119 million from the economy each year resulting in less money spent within the local economy, affecting local business and resulting in fewer local jobs.

With the limited scope for minimising the impacts of welfare reform at a local level it is essential that the most is made of local resources. This will need joined up working across councils, health, voluntary and community sectors and local businesses.

Public health has a role in raising awareness of the changes and the health impacts across all parts of the council and partners. It can also support the mapping and analysis of local impact, helping identify the local priorities for action and ensuring local plans are evidence based and monitored effectively.

Welfare reform is here, it comes with a real risk of significant negative impacts on health and inequalities at both local and national levels. Public health in councils needs to recognise this and ensure that it is fully involved in local efforts to minimise these impacts. At a regional and national level public health must lobby for changes to policy to protect population health and the disproportionate effects on the most vulnerable.

(1)Institute of Health Equity (2012). The impact of the economic downturn and policy changes on health inequalities in London.

(3) Beatty C, Fothergill S. Hitting the poorest places hardest: the local and regional impact of welfare reform. Centre for Regional Economic and Social Research. 2013

(4) Oxfam GB. (2010) A gender perspective on 21st century welfare reform.

(5) Welsh Government. (2013) Analysing the impact of the UK Government’s welfare reforms in Wales – Stage 3 analysis.

(6) Inside Housing (2013) Rent arrears up in wake of bedroom tax.

(7) Trussel Trust (2013) Increasing numbers turning to food banks since April’s welfare reforms.

(8) Sandwell Trends: Welfare Reform Topic Page (2013).

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By Alan Maryon-Davis, honorary professor of public health at Kings College London and past president of the Faculty of Public Health

WE love our NHS, despite its failings. We trust it, we depend on it and we cherish its fundamental principles of fairness and universality – free to all at the point of use.

Born out of Beveridge, midwifed by Bevan, the safe arrival of the infant NHS in the aftermath of war was nothing less than a revolution – the sort of massive change that could never happen today. It was huge – so big it dwarfed outer space.

Now, as we all know, the NHS is under threat – weighed down by the ageing population and high-tech hypertrophy, harried by small-state politicians, encircled by drooling marketeers  and asset-strippers.

The NHS is accused of being too monolithic, lumbering and unsustainable. The Government’s response has been to claw back millions of pounds and fire an explosive harpoon into its belly. The 2012 Act has torn into the flesh of the NHS, damaged many of its vital organs and put it on the critical list.

But it’s not dead yet. They have underestimated the power of the people. The NHS is healthcare of the people, by the people, for the people, all for one and one for all. This is why so many of us feel so passionate about it – and why we delighted in seeing it celebrated in the Olympics opening ceremony.

I believe the NHS at 65 is still, fundamentally, in good shape – in spite of all the ‘efficiency savings’, all the sniping and Cassandras, all the barbs, rug-pulling and clattering of bedpans in the corridors of Whitehall. The NHS can be nursed back to full health and vigour. Of course this requires political will – but political will is driven by the power of the people. And people power can be shaped and energised by the advocacy of those of us who feel strongly about defending the NHS and its fundamental principles.

We must seize this 65th birthday celebration to let everyone know that we will fight to make sure the NHS – the real NHS, not just the logo – is here to stay.

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by John Middleton, Vice-President of the Faculty of Public Health

The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Wordcloud: Adjusted responses (phrases/themed/categorized), first 200 responses (max 50 phrases)

Credit: Andrew Hood, using wordle.net

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now.  The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
•    An independent and robust Public Health England;
•    A coherent career and training structure for public health professionals;
•    Protection of terms and conditions of staff;
•    Directors of public health reporting to chief executives of councils,
•    Clarity in the size and applications of the ring fenced budget and
•    Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage.  However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began.   NHS planning has historically relied on regulations and guidance, not legislation.  This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog.  It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.

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By Mark Weiss, FPH Policy Officer

As the Health and Social Care Bill makes its journey through the Committee Stage at the House of Lords, FPH continues to actively engage with members, key stakeholders, parliamentarians, as well as through its representation on strategic working groups and supported by its wider media work.

Committed to ensuring the Bill will provide the structures and safeguards necessary to protect and improve the health and wellbeing of the people of England, FPH is working hard to ensure a strong and viable public health workforce is maintained and strengthened for the future; and a rigorous framework for the statutory registration and regulation of all public health specialists to protect the public is established. 

As we continue to press hard for amendments to the Bill, at the forefront of our minds the risks to the public posed by the Bill – E.Coli, SARS, pandemic flu, Buncefield, heatwaves, flooding, immunisation and screening – loom large. To meet this challenge, with Lord Patel taking a lead on FPH’s amendments, we maintain a focus on statutory regulation; the role, qualifications and accountability of directors of public health; the organisation independent of Public Health England; public health expertise in the new NHS Commissioning Board; employment conditions for public health professionals at parity with the NHS.

Over the past few months, FPH has developed and implemented a firm lobbying strategy. We have written to all MPs and peers taking part in the Health Bill readings in both the House of Commons and Lords, setting out a clear case for our amendments to the Bill. We have the support of a broad range of peers from across all political parties – and have regular meetings with peers to discuss the possible impacts of the Bill in the context of public health.

We are also working with other health and public health organisations through our chairing of the PHMCC task group, and actively engaging with local government colleagues – including producing a joint statement with the Local Government Group. We also have representatives on key strategic groups, including the Public Health England Group (feeding into the development of the PHE Outcomes Framework) and the Workforce Advisory Group and have taken an active involvement in the NHS Future Forum Process with a submission recently sent in for the Second stage. FPH also maintains close working relationships with other faculties, Royal Colleges and stakeholders to share information and horizon-scan.

Informing our position, three member surveys have been conducted to ensure that we are engaging our members in a full and meaningful dialogue. At present we are in the process of analysing the results of our latest survey of members’ views of the Health Bill, with a full analysis to follow shortly. In addition, FPH works closely with its Local Board Members to encourage their active engagement with local MPs and relevant stakeholders.

Our lobbying work around the Bill has been supported by our wider media work, delivering news articles including a recent response to the Health Select Committee 12th Report on Public Health appearing in the Guardian (a copy at this link); and letter to the Times outlining our key concerns with the Bill. In turn our monthly bulletin continues to keep all of our 3,500 members abreast of the latest developments.

For all the latest news on our work on the reforms visit www.fph.org.uk

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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.

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By Alan Maryon-Davis

The public health white paper promises to ‘improve the health of the poorest fastest.’ Health Secretary Andrew Lansley has said that closing the health inequalities gap is a top priority, echoing the Marmot Review – ‘more must be done to tackle the causes of the causes of ill-health.’ To this end he has set up a cross-government committee on public health and has proposed a shift of responsibility for health improvement onto local government, along with a ‘ring-fenced’ public health budget. Joined-up at the top and bottom.

So far, so good. Many would agree that local government is the natural home for the public health and wellbeing agenda. It’s where the big local decisions about social determinants take place and where a properly coordinated approach could really pay off. Localism in action.

The flipside of course is that the Coalition’s Health Secretary, with one deft move, will be off-loading this most stubborn of health challenges. Despite massive investment by the previous government, the inequalities gap has continued to widen. In taking on this agenda, local authorities might find themselves accepting a poisoned chalice.

If that was apparent before the Chancellor’s spending review, how much more so it is now we know the breadth and extent of Osborne’s austerity drive. Massive cuts in benefits and public services, soaring unemployment, a deep-frozen NHS and the rise in VAT, all add up to millions more people in difficulty – a situation which, according to the Institute for Fiscal Studies, is bound the hit the poorest hardest.

We know that maternity problems, infant ill-health, low uptake of childhood immunisation, poor oral health, child and adolescent mental ill-health, accidents and violence, depression and suicide, cancer diagnosis and heart disease, and the debilitating dependency of old age are all strongly linked to social deprivation. We can surely expect a huge upsurge in demand on the NHS – at a time when services are already overstretched.

As ever, it will be the disadvantaged who will miss out. The health inequalities gap is bound to widen and no amount of shifting the public health deckchairs, as envisaged in the public health white paper, can stop it. Indeed the distraction and planning blight that comes with the wider NHS reorganisation laid out in the Health & Social Care Bill can only add to the barriers faced by disadvantaged people.

The Health Secretary no doubt sees all this, but is determined to push his changes through, despite a barrage of opposition from many quarters. His view is that, whilst things will be tough in the early years, there are green Elysian Fields beyond. In the meantime, we can help him to get it right by responding to the White Paper consultations and cajoling our MPs to amend the Bill as it goes through Parliament.

A key issue is the ring-fenced budget for public health, particularly for the health improvement element that will be passed to local authorities. We don’t yet know the size of the ring-fenced allocation at national level, although a figure of about £4billion has been bandied about. That sounds a big number – but by the time the many millions have been taken out to support the work that the Health Protection Agency is currently doing, and the National Treatment Agency for Substance Misuse, and national campaigns, and various other central initiatives, the amount distributed to local level will be much truncated.

And then that local pot gets divvied up between the Public Health England unit, public health support to GP consortia, prevention activity by GPs, immunisation, screening, drugs and alcohol, child health checks, health visiting, etc etc – the list goes on. So, what will be left to hand over to local authorities to tackle the health and wellbeing agenda? Not a lot, I suspect. Local authorities (and their Directors of Public Health) will be taking on a huge added responsibility with very little resource to throw at it. More for less indeed.

And those LAs struggling to improve their health outcomes because of challenging demographics could find themselves further disadvantaged by the Health Minister’s proposed ‘health premium’ scheme. The intention is to reward only those LAs who ‘make significant progress’ towards better outcomes, including reduced health inequalities. But those of us who have worked with multi-deprived populations know how difficult this can be, despite heroic efforts, without major demographic change. Although we’re told the health premium assessment would take deprivation into account, there’s every chance that yet again it would be the more disadvantaged populations who miss out on any extra funding. So much for improving the health of the poorest fastest. No, as bright ideas go, I can’t help thinking this isn’t one of them.

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