Feeds:
Posts
Comments

Posts Tagged ‘Michael Marmot’

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.

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 »

By Matthew Day, Public Health Registrar, NHS Wakefield District

When I started my public health training I had a three day local induction to get to know colleagues and learn from a range of speakers in public health from around the Yorkshire and Humber region. I found it useful as it provided inspiring insights and top tips on how things work in the specialty, as well as the time to connect with new colleagues. But while different deaneries strive to bring local trainees together through induction programmes and local events, how would it work nationally?

The idea of developing a ‘corporate identity’ for public health trainees was floated at the recent Public Health Futures event, organised by Sir Muir Gray and the Informing Healthier Choices team. Despite sounding like management speak, the fundamental point is a good one. While we all fight different public health battles at local, regional, and national levels, a better networked public health workforce developed through years of training would only be of benefit.

Sir Muir described his vision of the CMO welcoming all the new trainees personally. I can imagine the event: a handshake and pat on the back each, the CMO maybe throwing in a visionary comment about future public health challenges:

Trainee 1: “Er…hello Sir….

CMO: “Welcome to our specialty, son. Go forth and reduce inequalities…”

And then at the induction dinner that evening:

Trainee 1: “What did he give you?”

Trainee 2: “Coronary heart disease.”

Trainee 1: “You think that’s hard, I got inequalities…”

Jokes aside, rather than a pie in the sky idea, the underlying concept of a ‘national public health bootcamp’ for the new 2010 trainees has some merit.  Trainees 1 and 2 would stay in touch, collaborating, sharing and not duplicating important work on their interrelated subjects. In fact, this vision was already being taken forward after the event in the shape of the new national trainees’ website.

With Sir Liam Donaldson’s video message, and his imminent departure from Westminster, there was also a strong sense of the public health baton being passed on to us. Indeed, the baton we inherit bears the labels of a mix of hefty issues: obesity, alcohol (particularly minimum pricing), sustainability and health inequalities. In a show of hands vote, the majority of trainees in the room voted health inequalities as the single most important issue for our generation.

But very often public health is also about getting the right messages across to an audience, and doing it well. At the event, Sir Muir Gray quipped that “public health is about ‘performance,” and with his keynote speech Sir Michael Marmot gave a master class in how to engage with an audience. Indeed, in the shadow of a forthcoming election where spin-doctors are drawing battle-lines between ‘substance’ and ‘performance’, the message I took from the day as a whole is that we in public health must be experts, world leaders even, at both. We must deliver top-notch quality science and evidence base for our work and continually improve how we communicate that science and evidence base to an audience, be it the public, policy makers or the health sector.

National networking amongst trainees is certainly needed to help develop these skills so perhaps the sooner we’ll be pulling up those boots the better.

  • See the slides from the Public Health Future’s ‘Killer Slide’ competition with some brilliant examples of robust evidence base and great communication skills coming together

Read Full Post »