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

Anita Roy

Position
GP,
Comment date
06 March 2013
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.

Anita Roy

Position
GP,
Comment date
06 March 2013
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.

charlotte klass

Position
Dental Public Health Registrar, London,
Comment date
31 October 2012
I would really love to hear more about your interesting community involved project. Could you send me more details. Thank you Charlotte Klass

Gavin Routledge

Position
Director,
Organisation
Fitmark Ltd
Comment date
03 October 2012
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?

Jo Somerset

Organisation
BikeRight!
Comment date
31 August 2012
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.

Dr Simon Abrams

Position
GP - Everton, Liverpool,
Organisation
Great Homer Street Surgery
Comment date
28 August 2012
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.

Tony Trigwell

Organisation
PPG Member
Comment date
28 August 2012
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.

Jonathon Tomlinson

Position
GP,
Comment date
24 August 2012
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

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."

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.

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