– by Dr John Middleton
– Vice President, Faculty of Public Health; formerly director of Public Health for Sandwell, 1988-2004
When I first came to Sandwell in 1987 it was in the depths of recession. In health services there was no local mental health service, no palliative care and much general practice was single-handed out of shop fronts. Waiting lists for basic elective procedures could be up to four years. Over half the population was living in poverty. There were 120 high-rise blocks and nearly fifty thousand council houses. Less than half of all children were immunized against measles and other childhood immunisations were less than satisfactory.
There have been great advances in health and health services provision. Progress began in the early 1990s and became exponential in the early 2000s. Even nine-month waits for operations were no longer to be accepted. They had to come down to 18 weeks. And no more than 4 hours in A&E. Services for people with serious and enduring mental health problems were improved substantially in the early 1990s. Over many years there have been improvements in community based palliative care, with fewer people dying in hospital.
In my final annual public health report for Sandwell, ‘ Public health: a life course’, I have reflected on some improvements in outcome. Heart disease deaths have gone down by an astonishing 2/3rds. Some of this is reflected in the long-term trends. But those trends have been influenced by the new and evidence based services, which have been implemented across the country over the years. We can point to improvements made in Sandwell, which have reduced deaths faster than the national rate and have reduced our gap in life expectancy with the national rate. Most recently, our GP based risk management system has saved more than 70 lives a year and closed the gap with the national life expectancy. Not a bad result considering heart disease deaths went up in the mid 2000s. I believe this was a cohort effect. The group of men thrown out of work in the 80s were dying prematurely from heart disease, brought about by a lifetime without work, hope, and probably smoking, drinking and being inactive.
Teenage pregnancy has come down by 44% since 1998. This I attribute principally to rising expectations in education. From 2007, exam results went up and teenage pregnancy came down. Over a number of years, it ceased to be acceptable to attribute poor results and low expectations for our children to ‘the deprivation’. If one teacher, or one school could make a go of educating children under difficult circumstances, they would all be expected to. In health, there were also some excellent services built up painstakingly over a number of years, in personal social education, young people’s contraceptive services and morning after pill availability from pharmacists.
The fact that teenage pregnancy has not gone up again in the latest recession is, I think, due to the insulating effect of the Surestart programmes, which began in 1998. Surestarts gave support to parents from deprived backgrounds, Surestart plus gave additional support to teenage mothers and Surestart maternity grant gave some financial support to pregnant mums. Most recently the Family nurse partnership has provided additional support to young mums. The policy advisory team from cabinet office that came to Sandwell in 1998 expressly set out the idea to support teenage mothers at that time, to break the cycle of babies born to teenage mothers then, becoming themselves teenage mothers 16 years on, I think we are seeing the benefits of that.
There has been an outstanding achievement in improving Sandwell homes to Decent homes standard. In our local research which we plan to publish, we have found much larger health effects in reducing cold related deaths and hospital admissions than have previously been reported.
There has also been the excellent achievement of Sandwell probation service in having the lowest reoffender rate in the country. The health component of crime reduction this has been considerable- in tackling drug and alcohol related crime, responding to domestic violence, providing appropriate care for mentally disordered offenders and supporting community development programmes to combat violent extremism. The recovery agenda for drugs and alcohol related offences has been a substantial contributor to reducing reoffending.
On a downside, there is much for my successor Jyoti Atri, to pick up on and deal with. Tuberculosis rates remain stubbornly and unacceptably high. It is normal to be overweight in Sandwell. Infant death rates have not reduced in the last 15 years. The West Midlands has the highest perinatal and infant deaths in the country and they have not come down as fast as they have elsewhere. The West Midlands has the highest rates of child poverty and the highest rates of obesity in the country both known risks in terms of infant health outcomes. We also need to review our antenatal policies, particularly with regard to growth monitoring in utero. I have recommended that Sandwell should commission an expert review of infant deaths, preferably with other councils in the West Midlands conurbation. The review would look at how we should prevent deaths, and what might be needed in improving care in pregnancy and childbirth.
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