Improving the health of the poorest, fastest

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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.

Comments

Jonathon Tomlinson

Position
GP,
Organisation
NHS
Comment date
23 August 2012
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/

Shaleen Meelu

Position
Director,
Organisation
www.healthy-futures.net
Comment date
23 August 2012
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.

Dr Malcolm Rigler

Position
GP,
Organisation
Partners in Health (Midland) Ltd.
Comment date
23 August 2012
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.

Sunita Berry

Comment date
23 August 2012
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.

mike collins

Position
visiting prof,
Organisation
U of Glos
Comment date
23 August 2012
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.

Mary Hawkins

Position
GP,
Comment date
23 August 2012
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?

John Kapp

Position
Director,
Organisation
Social Enterprise Complementary Therapy Co. (SECTCo)
Comment date
24 August 2012
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.

Dr Rober Macdonald

Position
Architect,
Organisation
LJMU
Comment date
24 August 2012
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.

Jonathon Tomlinson

Position
GP,
Organisation
NHS
Comment date
24 August 2012
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.

Nick Hopkinson

Position
Chest Physician,
Organisation
NHS
Comment date
24 August 2012
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."

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