Improving the health of the poorest, fastest

When the coalition came to power I, like many others, was nervous about whether the government would see inequality reduction as one of its core aims. However, whilst its related policy choices can and should be debated, its explicit acceptance of the Marmot Review and its commitment to 'improving the health of the poorest, fastest’, shows that inequality reduction is an important policy goal for government.

The government has also been as busy on public health reform as it has in the NHS; continuing to produce a raft of public health strategy documents around key risky lifestyle behaviours such as smoking, obesity and alcohol, and supporting the Responsibility Deal and campaigns such as Change4Life. The latest steps include the intention to adopt a minimum price for alcohol and the consultation on plain packaging for tobacco.

However, whilst there is continual evolution in policy on individual behaviours, we tend to hear much less about how unhealthy behaviours cluster together in different population groups, and how that in turn may relate to inequalities in health. We think this is an important, complementary way at looking at behaviour change and have published a study of how four common lifestyle behaviours – smoking, non-adherence to guidelines on fruit and vegetable consumption, excessive consumption of alcohol and low levels of physical activity – cluster in the English population and how that is changing over time.

We used two waves of the Health Survey for England and found that between 2003 and 2008, the proportion of the population who had three or four of these unhealthy behaviours fell significantly, from around one in three adults to around one in four. This is really good news, since we know – from a long-term study on the combined impact of health behaviours and mortality that followed people over time, using similar metrics – that after an average of 11 years follow-up, about one in four people with all four behaviours had died compared to just one in 20 of those with none of them. Any news that the population as a whole is moving ’down the ladder’ of multiple lifestyle risk therefore means saved lives.

The bad news is that the large majority of the improvements have come from people from high socio-economic groups and with higher education levels. Although there did not seem to be any worsening over time, the poorest and least educated saw no improvement over the five years between health surveys. This means that relative inequalities have increased and are becoming more polarised. For example, the chances of someone with no qualifications having four unhealthy behaviours compared to someone with higher education increased from three-fold to five-fold over the period.

We can only speculate on why we have seen these changes. The old adage that more research is necessary is very true, since this is the first study we’re aware of that has looked at change in this way in the English population. This type of research can provide a valuable tool for the government to help it achieve its aim to increase the health of the poorest, fastest.  But it does raise serious questions about whether a focus on single behaviour approaches, whilst necessary, are on their own sufficient in relation to inequality goals.

Whilst central government can help in setting laws and regulating industry and prices, much of the future responsibility for behaviour change will lie with local authorities. Understanding the very specific ways that behaviours cluster in local patches will be important if efforts are to be rewarded. Re-analysing local health and wellbeing surveys along the lines above is a simple first step to doing this. Beyond that, there are some great examples already of where 'every contact counts' is starting to inform the work of local authorities as a whole. We also believe there is great potential in the existing health trainer and community champions networks to make a real impact on reducing the evident inequalities in the clustering of behaviours our report has unearthed.

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Comments

#1370 Jonathon Tomlinson
GP
NHS

The findings should come as little surprise to anyone who spends their working day looking after patient from the most deprived sections of society. As I have blogged in detail abetternhs.wordpress.com/2012/06/24/perfect-storm/
and abetternhs.wordpress.com/2012/08/18/medical-advocacy/
and as the Deep End project in Glasgow has shown, when your future prospects look hopeless and you life is lonely and miserable, there's little reason to make changes to your behaviour now in order to add years later. I doubt very much that focusing attention on individuals or doing 'more research' will be of any benefit. (see Prof Trisha Greenhalgh: Less Research is Needed) blogs.plos.org/speakingofmedicine/2012/06/25/less-research-is-needed/

#1371 Shaleen Meelu
Director
www.healthy-futures.net

I am one of a group of trainers hired by the SHA in the East Midlands to deliver MECC 'Make Every Contact Count' sessions to Trusts across the country. Although we have only just started, this is proving to be a fascinating experience. The training includes a focus on developing communication skills to offer brief advice in relation to diet, weight management, physical activity, alcohol intake, mental health and sexual health. I've described the first session I delivered in a blog post healthy-futures.net/Blog/Entry/training-the-trainer-to-mecc.html. The reason this session was successful was because the Public Health Team who commissioned the training adapted the presentation so it was relevant to the local population. Individuals working in Health Improvement area often aware of the challenges faced by the local population however, services are not very well integrated or well known. Last week I delivered the 'generic' training to a Mental Health Trust. As their clients include individuals with complex mental health needs, older adults with health needs and groups with special education needs (also in areas of deprivation) - it is clear a different approach is required to support individuals make positive lifestyle choices. Again this requires input from specialists and those with local intelligence to help implement an integrated health improvement strategy. This isn't easy but at the very least, those that want help should be aware of where to go for it. Apparently 70% of smokers want help quitting for example and many of those I meet would like help loosing weight and improving their diet - from all backgrounds.

#1372 Dr Malcolm Rigler
GP
Partners in Health (Midland) Ltd.

Some years ago Prof John Macdonald wrote in Occasional Paper No 64 -RCGP that what is needed is "a huge and sustained educational programme" to be developed as part of our Primary Care Services. That education needs to be offered in all areas especially in areas of multiple deprivation "in language and terms people can understand" . The education - of local residents in such areas needs to be funded by the "Health and Well Being BOards" with a great emphasis on the creation and development of projects like "The Pub is the Hub" i.e. projects that promote and develop safer and more stimulating environments both within the built environment , the green infrastructure and the psycho social environment. Few practitioners within either the NHS or Local Govt. seem to have what is necessary to challenge the almost taken for granted assumption that individuals can change their behaviour on their own. The Peckham Experiment ( see thephf.org and The Mary LAngman Prize) proved long ago that our attention needs to be on the environment and that architects and town planners need to be fully engaged with Health Promotion as is now developing in Liverpool.

#1373 Sunita Berry

What if we did nothing? Walking on the streets, it often seems that we do nothing but continue to assume that just because we have created a raft of 'health interventions' and 'health interventionalists' with only occasional contact, somehow we are actually producing health. The business of health production is complex and in creating and developing a number of 'health professionals' to look after the so called feckless, we only increase the numbers of the middle class who can continue to look down on those who's health they are paid to look after. Let the poor migrate to the middle or even the upper an over time we will see the biggest change in health production. However, the economy and societal structure militates against - and the poor, they will always be with us.

#1374 mike collins
visiting prof
U of Glos

I agree wholly with Nick's comments but what is needed is a sustained social marketing campaign like that against seat belt non-use and smoking; much more robust than the fuzzy/warm Change54Life, because although physicla activity has no institutional enemies unlike smoking drinking and dieting, it requires effort to give up TV get out fo the house and be willing to put up with sweatiness and aching muscles. See International Journal of Social Marketing 2011.

#1375 Mary Hawkins
GP

Changing habits - or setting up the systems to change eating habits - usually isn't an *individual* decision.
If you can convince "mum" (technical term for the individual who buys and cooks for the fanily) you still have the other half's ingrained habits, and kid pester power.
And - as with everything else - most bad eating habits are enjoyable..;-<
Young people - any generation - cannot conceive that life could be worth living after something like 10-20 years above their current age: but this is the generation we need to convince..
Ideas?

#1376 John Kapp
Director
Social Enterprise Complementary Therapy Co. (SECTCo)

I agree with all above that education should be part of primary care. The word 'doctor' comes from latin 'doctare' to teach. We have just bid to run 600 therapeutic courses in Brighton and Hove next year prescribed by GPs for the Community Mental Health Prospectus, see www.sectco.org, but our bid has been turned down.

#1377 Dr Rober Macdonald
Architect
LJMU

As an Architect I am helping Dr Simon Abrams GP in developing a User Friendly Surgergy in the Everton Inner Area of Liverpool. We have held various meetings with residents and have discussed the nature of Health and Well Being with working class patients of Simon. The team also include Film and Sound Artists Moira Kenny and John Campbell. They are creating a film called 'The Waiting Room'. Residents and patients are playing an important role in this production. We hope that 'The Waiting Room' will be shown on the 'Big Screen' at the Foundation for Art and Technology in Liverpool.

#1378 Jonathon Tomlinson
GP
NHS

As a GP I'm interested in patient-centred medicine. It is up to the patient to prioritise their health needs, not the government -which is happy to hand public-health policy responsibilies to junk-food and alcohol manufacturers, whilst insisting we should be freee to smoke, eat and drink what we want, and furthermore have it adertised at the olympics -and in higher concentrations in poor areas than wealthy. In Hoxton Street where I work and the Narrow Way where I live there are fried chicken shops, betting shops and pawn brokers every few yards. Every grocers sells cheap booze and most sell cheap, under the counter fags. Every street corner has a smack dealer. The individualisation of public health policy is a deliberate de-politicisation of health, an negation of public-political duty and an attack on the poor. It's time to refresh ourselves with Virchow.

#1379 Nick Hopkinson
Chest Physician
NHS

I would have thought that the fact that it is cutting taxes for people earning more than £150,000 per year makes it rather unlikely that "inequality reduction is an important policy goal for government."

#1380 Jonathon Tomlinson
GP

It's not the behaviour of the poor we should be concerned about, it's the behaviour of the corporations: Why corporate power is a public health priority (BMJ) bmj.com/content/345/bmj.e5124

#1382 Tony Trigwell
PPG Member

Anyone who has seen the Kings Fund research will understand the weight of evidence and therefore the importance of reducing multiple lifestyle risks. What is stark contrast between different socio-economic groups and what appears to be recognition or take up amongst the less well off. Having identified the differences the new challenge is to find out WHY! Only then will we be able to influence the choice that people have to; stop smoking, drink less alcohol eat more wisely and exercise more... THE BIG GAP IS (as has been said before) EDUCATION. That will cost time and money and should be addressed urgently by the government. Leaving it to overworked GPs will take to long.

#1390 Dr Simon Abrams
GP - Everton, Liverpool
Great Homer Street Surgery

The large scale change being talked about requires big changes in thinking. As a GP with 15 years experience in Everton, Liverpool, one of the areas in the UK with a very high score on the index of multiple deprivation, it is increasingly apparent that the disease model we still focus on in General Practice is becoming outdated. Rather than disease, GPs need to be talking about wellbeing with patients.Sneakingly I suspect that many patients already know that - they want health advice but they often get "medicalised" advice which they dont follow. The arts project at our surgery, mentioned by Dr Rob McDonald above, is exploring some of these issues with the patients at the surgery. We are also doing some work with the local Friends of Everton Park Group and the Cass Foundation, which seeks to find ways to improve health by improving places, to provide wellbeing opportunities for our patients. GP practices around the country have huge social capital - if that capital focussed on wellbeing, rather than disease it might be part of the solutions that David Buck and subsequent contributors are calling for.

#1400 Jo Somerset
BikeRight!

I've sat on a major hospital Trust board, and my day job is outside the health industry. However, I believe helping people to adopt habits of cycling and walking will have more effect on remedying the impact of the 'top 4' behaviours than many interventionist programmes - without mentioning the word 'healthy' at all - as well as providing environmental and economic benefits. The key is to catch the imagination of people in poorer communities for whom being generally active has multiple rewards for wellbeing, as mentioned by the comment above.

#2077 Gavin Routledge
Director
Fitmark Ltd

Health behaviours are contagious. As NICE indicates, health behaviour change programmes need to be contextual. The "solution" must lie in programmes that are community centred but apply the same principles. Allowing people to start where they are (autonomy), but join together as groups (relatedness) and feel that they are achieving something worthwhile (compentence) is a good start. Within any programme, guidelines must be simplified so that the population can apply the knowledge easily.
The growth of smartphone use (>30% of mobile phone users) affords a fantastic platform to provide interventions which will put "hot triggers in the paths of motivated people" (BJ Fogg). I haven't found out yet what the societal variations are in smartphone ownership. But there is no doubt, the more we target "problem" groups with "contextual" programmes, the better chance there is. I love a challenge!!
Dr Abrams (and others), I'd love to know what proportion of your patients you think have smartphones?

#6380 charlotte klass
Dental Public Health Registrar, London

I would really love to hear more about your interesting community involved project. Could you send me more details. Thank you Charlotte Klass

#40141 Anita Roy
GP

I'm with Jonathon Tomlinson on this. Social marketing and health education of whatever sort will have a minimal impact on the poorest people, who can't see why they might want to extend their lives. Try improving parenting, and early years education, but principally give more people a chance as per Marmot.

#40142 Anita Roy
GP

Would David Buck please remember that Government action speaks much louder than fair words about implementing Marmot. I think recent events show it's more about demonising the poor, and privatising public services.

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