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Posts Tagged ‘Inequalities’

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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By Dr Steve George, FPH Vice-President

Andrew Lansley’s commitment to public health, brought out in his interview with the Society Guardian (14/04), is welcome, but prompts a number of questions. The Conservative party’s health spokesman suggests that the Department of Health would be renamed the Department of Public Health, and that it would be given a new focus on prevention of illness. But if this was to translate into a genuine improvement in the health of the public, much more than the name of the body responsible for health would need to change.

Fundamentally, much of the Guardian interview is still focused on health care, or what might more aptly be called ‘illness care’. The public, and the politicians who represent them, must grasp the fact that ‘illness care’ has at best a tiny influence on the health of the public. Only after this realisation can there be any genuine change in the health of the public.

History has shown us that past improvements in health have appeared more as a by-product of a rising standard of living, rather than as a result of conscious policies to improve health. Certainly clinical medicine provides reassurance. It provides care and comfort. It provides treatment for acute emergencies. In certain instances it can provide cures, but these instances affect only a small proportion of people with morbidity. The USA and the UK have approximately equal life expectancies, despite the fact that the UK spends per head of population around a quarter of what is spent in the USA on health services.

So what about the proposed Department of Public Health? Lansley pledges that under a Conservative government patients would be given unprecedented detail on “good and not so good care.” Would this improve public health? Not a bit – even if patients learned the skills of adjusting results for case-mix – the mix of patients treated by a hospital/unit – and other confounding factors that are the bread and butter of people working in mainstream NHS public health.

What about the Tories’ proposal that hospitals would be paid variable sums based upon the quality and results of treatment? Would this produce improvements in public health, assuming that those results were interpreted correctly and correct measures of “quality” were in place? No, for the same reasons as above. It would almost certainly, however, make those responsible for hospital budgets reluctant to attempt to treat a patient likely to produce a poor result, and thereby drive down their tariff. And it’s by no means clear how a policy that would inevitably result in hospitals with poorer facilities and less well trained doctors receiving less funding would accord with the Tories’ promised moratorium on hospital closures.

What might improve public health is channelling money into improving social infrastructure in socially disadvantaged areas and reducing income inequalities. But neither seems likely, given that those inequalities have worsened over decades under successive governments of whatever political colour.

What we are likely to see instead is another health service reorganisation, and I’ll end with a quote often attributed to the Roman orator Gaius Petronius Arbiter:

“We trained hard, but it seemed that every time we were beginning to form up into teams, we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.”

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Very exciting news indeed.  Dame Tanni Grey-Thompson, 11-time Paralympic gold medallist, has been confirmed to give the keynote speech at our Annual Conference in London on 7 July.

Dame Tanni will provide  a truly inspirational start for what promises to be an action-packed day. Sue Tiballs, Chief Executive of the Women’s Sport and Fitness Foundation (WSFF) will be there to introduce her – Dame Tanni is  Chair of the Commission on the Future of Women’s Sport.

Other  speakers confirmed for the Conference include:

Professor Julian Le Grand, former No 10 Downing Street advisor, and Anna Dixon, Acting CEO at King’s Fund, taking part in “The Cuts Debate: Where Should The Axe Fall?” Chaired by Adam Brimelow, BBC Health Correspondent

Dame Carol Black speaking at the “Our Ageing Society: How Do We Meet the Challenges of the Next Decade?” – session

Denis Campbell, The Guardian, Mary Riddell, The Daily Telegraph and Dr Tony Jewell, Welsh Chief Medical Officer, discussing “Unhealthy Headlines: How Do We Prevent Another MMR Scare?”

Professor Martin McKee, London School of Hygiene and Tropical Medicine on the panel for “Cityscapes – How Do We Create Healthier Cities?”

• Samantha Callan, Centre for Social Justice Chairman in Residence, Chris Bentley, Head of Inequalities at Department of Health, and Peter Kellner, President of YouGov, at “Hard Times: Reducing Inequalities in a Tough Financial Climate”

The theme of this year’s Conference will be “The Next Decade: What Is The Future Of Public Health?” and we’ve got sessions on issues as diverse as the economy, the challenges of the new government and the effectiveness of health protection campaigns.

And for the first time ever, the Conference will take place in London, at Imperial College.

So see you there!

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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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Sunday 8 November 2009

Early morning in Philadelphia. From my hotel room I watch the sun rising over the Delaware River.

Yesterday I saw a different sun rising – a motif carved on the back of the chair in which George Washington presided over the signing of the Constitution of the United States of America after months of wrangling in 1787. At the time, Benjamin Franklin, sage and polymath, whose knowing presence is everywhere here in historic Philadelphia, observed, ‘now, at length, I have the happiness to know it is a rising and not a setting sun.’

Yesterday I switched on the TV during an ad break. First up was one of the interminable screamers from the NO lobby in the great healthcare reform debate. What about the $800 billion bill? All those inflated taxes? Can they guarantee you can keep your own doctor? Your current insurance company? Can they promise healthcare won’t be rationed? Persuade your congress representative to vote NO for the Public Option.

Then in quick succession: an ad for the statin Crestor to control your cholesterol – ‘if you have difficulty paying for medication, Astra-Zeneca may be able to help;’ and Reddi-Wip real ready-whip cream – dessert just isn’t dessert without Reddi-Wip.

Today I switched on the TV and everything has changed. The House of Representatives has passed its sweeping healthcare reform bill by a narrow margin – 220 votes to 215. Although it still has a few hoops to jump through before it becomes law, the way is now paved for the biggest extension of healthcare insurance coverage since the introduction of Medicare 40 years ago. The vast majority of the 46 million Americans without insurance will, by law, have to be covered. The federal government will offer its subsidised insurance scheme (the Public Option) in competition with the established health insurers. Radical change will happen through a largely market-driven shakedown within a framework set by government.

Later today I will be attending the Grand Opening of the Annual Meeting of the American Public Health Association – a colloqium several thousand strong, held this year in Philadelphia’s magnificent convention centre which, rather like Manchester’s, was once a busy railway terminus.

You can guarantee the place will be abuzz with talk of the healthcare vote. The atmosphere will be electric. It will light up the whole conference. I doubt there’ll be a soul there who isn’t absolutely thrilled at the prospect of such a huge change to US healthcare. It is truly momentous.

Barack Obama’s powerful pre-vote speech invoked the call of history – rather in the same vein as the ringing statements of the Founding Fathers here in Philadelphia.  And, fingers crossed, it seems to have been answered. As Ben Franklin might have said, methinks the sun, at long last, shows promising signs of rising.

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