May 2004
Introduction
Public health is not a health care issue. It covers the widest spectrum of life experiences that can be influenced by government. It requires joined-up thought and action across a whole range of government departments and is an agenda that can only be co-ordinated successfully by a senior politician of Cabinet rank. The SHA believes, therefore, that the Prime Minister should immediately appoint a Secretary of State for Public Health to the Cabinet.
The SHA is disappointed that this consultation is led by the Department of Health, and would have preferred it to come from the Cabinet Office or the Office of the Deputy Prime Minister. The Association would like to be re-assured that all government departments will be fully engaged in the implementation of any future Public Health Act that will follow the publication of the public health White Paper.
A healthier population begins with healthier babies, and health literacy should be taught and learned in the schools. For this reason, the SHA’s response begins with a programme of public health interventions it would like to see implemented from birth, through childhood and into adulthood.
Pre-school
Sure Start is one of the most successful initiatives that this government has introduced, and it should be funded and mainstreamed across the country at the earliest opportunity.
Diet and nutrition
It is known that poor health and nutrition in pregnant women causes health problems throughout the lives of the resulting children, yet many are expected to subsist on benefit levels that are too low to support a healthy diet. There should therefore be an immediate increase in benefits paid to pregnant women, coupled with information and advice to enable them to live healthily during their pregnancy.
In the school
The National Healthy Schools Standard should be fully funded and mandatory at every school. Ofsted should monitor compliance; and compliance should be included in the local government comprehensive performance assessment.
Sensitive issues can be tackled head on in all schools. The topics of drug, alcohol and tobacco abuse are often avoided because they are controversial, yet children respond well to factual information on such matters.
Health literacy
Learning to live healthy lives should begin in the school, where young people can discuss their own and their community’s health. Informing children about the realities of drugs, the dangers of smoking, the need for healthy eating, sensible drinking, regular exercise, and the social, interpersonal and health aspects of sex are all elements of Health Literacy and should be an important part of the National Curriculum.
Diet and nutrition
Government should ensure that the duty of care owed by schools to their pupils is extended to their diet. Young children should not be free to eat too much fat, salt and sugar at school just because the damage done to their health is not immediately apparent. Vending machines that sell fizzy drinks and unhealthy food should be removed from all educational establishments, and commercial schemes that encourage children to eat unhealthy food to obtain “benefits” for their schools should be outlawed.
Free healthy meals should be available as a part of the school day for all children. This has been achieved in Hull, and other local authorities could manage this through the economies of scale of a borough-wide meals service and saving the costs of delegating budgets and creating unnecessary bureaucratic structures at each individual school.
Many children who are entitled to free school meals don’t take them because of the stigma. Universal provision would remove this stigma. Children could then be permitted to bring packed lunches from home only in the most exceptional circumstances (for example, those with severe food allergies).
Diet can also be used to approach indiscipline problems in schools, and is a much sounder approach than relying on medication for poorly defined conditions such as “attention deficit disorder”.
Cooking is an important skill in its own right, and government cannot assume that it is learned in the home. Budgeting, menu planning and shopping for healthy food, and cooking it, should all be part of the National Curriculum.
Children should be able to drink water throughout the day, and free school milk should be available to all.
Physical exercise and obesity
Regular sports, dance and other exercise for at least 45 minutes each day must be reinstated in the school timetable to tackle the increasing problem of childhood obesity. Two hours of physical education per week will not suffice.
Parents should be actively discouraged from taking their children to school in cars, and each school should be set a target to increase the number of children who get to school by walking, and by cycling where it can be done safely.
Sexual health
Education in sexual health and teenage pregnancy issues must not left to the discretion of heads, school governors and parents. The European experience indicates that this should start early in primary school.
Messages should be clear, unambiguous and emphasise risk reduction. Promoting abstinence is unhelpful. Much more use should be made of peer education.
Access to free contraception, including the “morning after pill” should be made much easier. Local authorities should not be permitted to prevent this, as some have attempted to do.
Mental well-being
Physical activities in the school should be complemented by a full arts curriculum to enhance every child’s self-esteem and mental well-being. Schools should be encouraged to play a significant role in positive mental health promotion and to implement anti-bullying measures that are really effective.
Accidents
All schools should have integrated road safety education programmes. These should be assessed in Ofsted inspections and be funded from ring-fenced money.
The role of government in improving health
The SHA recognises the dilemma the government faces in striking the right balance between persuasion and prescription over individual lifestyles. However, it believes that at the moment government errs much too far on the side of persuasion. The SHA urges government to lose its fear of being seen as a “nanny state” and to ignore the libertarian lobby.
Earlier prohibitions that were once controversial are now seen as straightforward common sense, such as the use of seat belts in cars, motor cycle helmets, and banning smoking on aircraft and public transport. Many “freedoms” that individuals claim for themselves can seriously damage the health of others and impose unnecessary burdens on health and social care. Government must be resolute in tackling them.
Initiatives that require early government action in the interests of improving health and reducing health inequalities include:
- persuading the European Union immediately to ban Common Agricultural Policy subsidies that support the production of sugar. This gives out a very mixed message when government is exhorting people to reduce their consumption of sweet foods;
- introducing a statutory requirement for local authorities and local strategic partnerships to carry out health impact assessments of all planning proposals and policy developments;
- legislating for a total ban on the advertising of unhealthy food directed at children;
- developing and promoting a comprehensive, long term nutrition strategy including a national obesity strategy, and providing the resources to enable councils and others to deliver it locally;
- requiring manufacturers to label all food and drink clearly with the percentage of salt, fat and sugar along with full details of all additives;
- complementing the ban on tobacco advertising with a similar ban on the advertising of alcohol, and removing loopholes in the existing legislation;
- introducing greater regulation of an individual’s early years of driving, including zero tolerance of alcohol use;
- introducing an immediate flat fee for a whole prescription, and exemptions for all medication for chronic and communicable diseases (pending the removal of all dental, optical and prescription charges);
- developing NHS Direct as a more pro-active source of quality assured health promotion advice;
- requiring independent healthcare practitioners such as GPs and GDPs to implement a common system of patient profiling, including ethnic coding, language/s spoken and cultural needs;
- asking the Office for National Statistics to review and amend its ethnic codes in consultation with health service practitioners to make them more precise, useful and comprehensive
The single most important thing that government can do, however, is to legislate to ban smoking in all enclosed public and work places, including places of entertainment. In the meantime, it should encourage and enable local authorities to do this through local bye-laws.
Evidence from California and elsewhere suggests that banning smoking in public and in the workplace can halve the population prevalence of smoking. While smoking cessation policies are effective, they also contribute to a widening of health inequalities, since they are far more successful with those in more affluent social groups. They should therefore be targeted better to reach socially excluded groups and reinforced with an outright ban on smoking in public. Evidence shows a majority of the population – for example, in London – now in favour of this.
Passive smoking seriously compromises the health of others, and if government is really committed to improving the health of the population, it must grasp this nettle and resist the blandishments of the tobacco industry and the libertarian lobby.
Alcohol misuse
Both government and local authorities should monitor carefully the effects of the new Licensing Act to ensure that this does not lead, as some fear, to increased alcohol consumption and all the consequences that this would involve, including domestic violence, traffic accidents and mindless street disorder.
Government should support and encourage local authorities to use their powers to establish alcohol-free zones in cities and towns.
Drug misuse
The SHA believes that it is now time to de-criminalise the use and supply of drugs. Government should recognise that prohibition has failed, and worse, that it has brought with it other issues such as organised crime, street crime and gun crime that all impact adversely on community safety and hence on health and well-being. Prohibiting the use of drugs is as futile as attempting to prohibit sexual relationships outside heterosexual marriage.
The only rational response to this evident truth is to provide the requisite drugs on prescription to addicts, within a regulated framework that assures an adequate supply, the purity of the drugs; and mandatory participation in a care, treatment and rehabilitation programme. This is what is done, more or less, with alcohol misuse.
The net result of such action would be a significant reduction in harm from overdosing and adulteration; and the elimination at a stroke of the crime associated with illicit drug use. And as a bonus, licit use would allow government to measure more accurately the true extent and nature of the habit, thus giving a better general insight into societal health and well-being.
The SHA contends that the legalisation of drug use and supply will have a direct and positive impact on health and well-being; and the indirect impact on crime reduction might be even greater, with a differentially beneficial effect on socially excluded communities living in areas of high deprivation.
The SHA acknowledges that this is not a matter to be addressed without a great deal of thought, consultation and debate, but it believes this is an issue that government should take very seriously. Other nations, such as Portugal, are able to accommodate this within the constraints of the United Nations resolution that prohibits such an approach, so presumably where there is a will there is also a way.
Transport and air quality
Improved air quality will have a significantly beneficial effect on health, and key to this is reducing the use of private cars. Government must take immediate steps to introduce an efficient system of fully integrated public transport that is affordable, pleasant to use and convenient for the traveller; and make it easier for distributors to use rail and waterways rather than roads.
Both national and local government should provide adequate funds for public transport, with subsidies where necessary. They should campaign to reduce the use of cars, encourage people to walk more and promote facilities for safer walking and cycling. Many cycle lane initiatives are half-hearted and do not make it easier for cyclists.
The massive increase in illegal cycling on the pavement is because cyclists do not feel safe – and indeed are not safe – sharing the streets with traffic. But pavement cycling means that pedestrians no longer feel safe. It is time for local authorities to promote separate pavement space to accommodate cycling that is safe for both cyclist and pedestrian, as is done in many countries on the European mainland. If this happens, then schools and local authorities can be given targets for increasing the number of children cycling to school.
Obesity
The failure of many PCTs to implement the Diabetes NSF is very worrying. There is a huge explosion in numbers of diabetic patients because of the incidence of obesity among other factors, and government seems to be backtracking on National Service Frameworks in general, giving them fewer teeth and treating them as aspirations rather than fully funded programmes.
This trend must be reversed if the NHS is not to face massively escalating costs for the treatment of diabetes in the future.
NHS entitlements
Government must review its decision to end free health care for failed asylum seekers. Denying preventive and basic health care could seriously jeopardise public health, quite apart from the ethical issue of leaving many people to suffer from chronic or potentially terminal illnesses for unspecified periods of time.
The role of the health service in improving health
The creation of foundation hospitals contradicts the important principle that the PCT is in the NHS driving seat at local level. PCTs make the key decisions about local priorities and the allocation of resources; and creating a more democratic and accountable NHS should have started there. PCTS are best placed to work jointly with statutory and voluntary sector partners to deliver improved health as well as health care to a local community. Focusing instead on foundation hospitals will only strengthen the already powerful secondary care sector at the expense of primary and community care, cut across the planning role of the strategic health authorities and inhibit the development of clinical networks between and across trusts. These shortcomings in turn will diminish the ability of PCTs effectively to plan and fund the care that reflects the needs and preferences of their local residents.
The suggestion that PCTs should devolve budgets and power to GP practices should be resisted, since this could also interfere with the PCT’s crucial local planning role.
Health inequalities
There is no sense in contracting out health care support services to an underpaid workforce. Securing the lowest tender price at the cost of impoverished workers should be recognised as the poor long-term bargain that it is.
Contractors make profits by cutting the terms and conditions of the lowest paid staff, many of whom are female and from black and ethnic minorities, and their own health suffers as a result. It would be interesting to conduct an audit of people with the poorest health within a community and see how many of them work in services contracted out by the public sector.
Unless and until all health practitioners undertake comprehensive patient profiling, including ethnic coding, in a consistent and universal form, it will never be possible accurately to identify people at risk of certain conditions, particularly those that are linked to ethnicity, nor to plan and commission services to address them. Patient profiling should therefore not be an optional add-on to the GP contract and must become mandatory as quickly as possible.
Accidents
Falls are a major cause of ill-health, especially for older people, and can be very serious owing to the prevalence of osteoporosis, particularly amongst women. Osteoporosis costs the NHS over £1.7 billion each year.
People often describe mental health services as the Cinderella Service, but in fact health care services for the prevention and treatment of osteoporosis really is a Cinderella Service. The recent NICE appraisal recommendations for the secondary treatment of osteoporosis appear to reinforce this view.
Government should initiate an early public health campaign around osteoporosis and review how it tackles the current epidemic. PCTs should employ trained staff routinely to deliver exercise programmes to the housebound and to everyone over the age of 70, particularly exercises that strengthen the neck of the femur.
The role of other parts of the public sector in improving health
Shared local objectives determined by PCTs, local authorities and others should be part of the planning and performance management of both PCTs and local government. The Health Commission should assess the performance of the public health role of PCTs and StHAs, and publish an annual report on the state of the nation’s health.
Health inequalities
There is scarcely a responsibility of local government that does not impinge on the public health agenda, and on health equalities in particular. Local authorities need wholeheartedly to accept that health is not just an issue for their local NHS, that a huge range of factors contributes to the problem and that they therefore also have a major part to play in health improvement and the elimination of health inequalities.
Councils and government have to work together to deliver the decent homes standard in social and private housing. The attack on fuel poverty must be pressed home through insulation and heating programmes involving the private and voluntary sectors as well as the local authority. Health and safety at work needs much more effective enforcement by the Health and Safety Executive and local authorities.
Welfare rights and maximising the take-up of tax credits, pension credits and council tax benefit, especially amongst those groups least likely to claim, such as pensioners, must be seen as part of the drive to promote good health. Environmental policy must reduce air pollution in residential areas. Police, local authorities and the alcohol trade need to tackle under-age and binge drinking. Community safety and local transport policies, together with improved access to leisure services and physical recreation, also have a part to play.
The second generation of local public service agreements that embrace central government, local authorities and other partners at local level should seek to reflect some of these concerns. There should be a greater flexibility to move money and resources across institutional boundaries and to “bend the spend” in pursuit of new approaches to tackle health inequalities.
Given an increased weighting in comprehensive performance assessments for effectiveness in dealing with these problems, and the role of councils in scrutinising health and social care, there is now a real opportunity for local government to lead the attack on health inequalities.
Physical exercise and obesity
Educational institutions should make their sports facilities widely available to their local communities. Local authorities should also ensure that their sports and leisure facilities are affordable for everyone and culturally accessible, for example, through the provision of women-only sessions.
More specialist children’s gyms should be established, since the equipment in adult gyms is not suitable for them.
Local authorities should preserve playing fields and other open spaces, introduce safe play environments within open spaces, address quality and safety issues and promote safe walking environments.
The role of industry in improving health – including food, alcohol and leisure
Government must work with the food, drinks and leisure industries to help them develop an informed and responsible public health approach to the merchandise they produce and the services they offer.
Manufacturers do their best to confuse the public about the health risks of many foods and drinks. The food industry should be urged not to use excessive amounts of sugar and fat in prepared foodstuffs, and salt should be excluded altogether where practicable. The addition of salt to any food ideally should be a matter of individual choice. Manufacturers should label all food and drink clearly with the percentage of salt, fat and sugar along with full details of all additives.
Retailers should be encouraged to display unhealthy merchandise, such as sweets, fizzy drinks and cakes at a high level, as is already the case with “adult” magazines.
Accidents
There is now incontrovertible evidence that men in fast cars, particularly young men, cause a disproportionate number of road traffic accidents. Manufacturers should therefore be encouraged to tone down the advertising that promotes cars for their speed and exploitation as “babe magnets”.
The role of the media in improving health inequalities
Government must mount regular healthy living campaigns through the media, supported by high quality, evidence-based public information on healthy lifestyles that are suitable for a wide range of audiences and available at local and community outlets. Ideally, sports stars and other celebrities and role models should front these campaigns. These same people should be discouraged from advertising unhealthy foods, particularly to children.
The role of the voluntary sector in improving health
The voluntary sector has a useful and natural role as an intermediary and link between the statutory services and local communities. As highlighted in the Wanless II report, it can advocate on public health issues, offer innovatory and bespoke services to local communities, contribute to the delivery of preventive healthcare, and fund and undertake research.
Health inequalities
Organisations situated within the voluntary sector, or at arms length from statutory providers, are uniquely placed and able to foster links with many deprived and hard to reach communities, including older people, many black and minority ethnic communities, people with physical and sensory impairments and users of mental health services. These links can be used to promote healthy lifestyles, to help hard to reach groups achieve good health, and to inform the practices of government, local authorities and industry in developing more accessible and user-friendly services.
The role of individuals in improving health
Government, the NHS, local authorities, businesses and the voluntary sector can all use their muscle to encourage people to develop health literacy and live healthier lives. However, most people already know what they have to do to become healthier, but lack the impetus to change. Haranguing people achieves very little.
Perfectly properly, much attention is devoted in government programmes and reports such as Wanless II to lifestyle issues and people’s responsibility to look after their own health. In particular, smoking, exercise, alcohol and diet have a critical impact on health and life expectancy. Clearly health promotion has a major role to play, but the correlation between social class, educational attainment and low income with these lifestyle issues suggest that health promotion in itself is not enough.
Raising the income, educational standards and life chances of the least well off are therefore crucially important components of the attack on health inequalities.
Barriers that prevent individuals becoming healthier
While individuals are responsible for their own health, they need support to make better decisions. This includes the provision of full information, the removal of ingrained attitudes and prejudices, and action to ameliorate the poor lifestyles and health literacy that are linked to social and economic disadvantage.
Income
Most poor people know what they must do to become healthy, but lack the means to do so. It is time for the UK to have a proper measure of the income level needed to avoid both absolute and relative poverty and to ensure good health, satisfactory child development and social inclusion. This measure should determine benefit, pension and minimum wage levels and should inform the practices of debt collectors and the courts.
Access
There should be an urgent review of all current charging schemes that inhibit poorer people’s access to services, treatment and care. This should include a reassessment of the recommendations of the Royal Commission on Long Term Care, the perverse incentive of intermediate and domiciliary care charges that drive people out of their own homes and into residential care, and dental, optical and prescription charges.
The SHA would like to see the abolition of all prescription charges.
Capacity
Increasing the supply of well-trained and qualified nurses, allied health care professionals, social workers, care assistants, and ancillary workers will make a huge difference to the provision of equitable services across all parts of the health care system, and also take the pressure off doctors. Encouraging the large pool of qualified nurses doing other jobs or not working to rejoin the service could increase the supply of nurses relatively quickly. Offering better terms and conditions of employment across the board to all NHS staff will also assist recruitment and retention.
Government and the NHS must address the institutional racism that under-values black and minority ethnic nursing staff and discourages recruitment from some minority ethnic communities. Action must also be taken to tackle the high drop out rate from training. Raising the status of nurses and changing the medical culture that treats them as second-class citizens will take longer, but clear signals should be given now. In the meantime, better pay and conditions, and more attention to team building and morale will help.
Finally, much more can be done to enable migrant and refugee health care professionals to update their qualifications and language skills to enable them to practice in this country. The British Medical Association now participates actively in this process. The British Dental Association participates more reluctantly, and should be urged to emulate the BMA.
Mental Health
Mental health policy appears to be in the grip of the law and order lobby, whose policies are misguided, counter productive and damaging to service users. There are many mental health issues beyond those around risk that need addressing, and the SHA recommends some public health interventions that it would like to see in the mental health arena.
The government’s decision to delay publication of the Mental Health Bill is welcome as a sign that it has listened to the overwhelming opposition to previous proposals. The SHA looks forward to the publication of a new draft Bill that incorporates the constructive suggestions made by so many mental health organisations.
In addition, the SHA believes that mental health care services should be the place where the government first implements its commitment to provide a wider choice of care, treatment and care providers for patients, other service users and carers.
Public education and tackling stigma
Government should build on its national Mind Out campaign by following the example started in Scotland in 2001, when a national campaign to improve mental health and well-being was launched. Government needs to work with voluntary sector organisations, the police, media, trade unions, service users, carers, and national and local voluntary organisations to develop a coherent programme with adequate funding behind it.
The attitudes of the public seem to be hardening towards people experiencing mental health problems and this influences their personal attitudes and behaviour in a negative way. Due to the stigma this engenders, people are suffering in silence and not coming forward to seek the help and support they need.
The media have a huge responsibility in the way they report mental health issues, bearing in mind that some tabloid newspapers seek to sell papers through a sensationalism that feeds the public’s ignorance and fear. This reinforces the stereotypes members of the public have of people with mental health problems.
Some work needs to be carried out within schools to educate children around mental health and well-being issues involving local education authorities, mental health services, health promotion, the DfES and the DoH, service user groups, national and local voluntary organisations.
Something also needs to happen to help school children who, as a result of bullying, commit suicide. Action to reverse this trend must involve schools, teachers, parents, LEAs and government departments.
The government is applauded for its commitment to suicide prevention. What is now required at both a national and local level is adequate funding, together with a properly co-ordinated campaign to reach out to vulnerable groups, such as young men.
Government could initiate a national media campaign, with t-shirts, beer mats, posters and leaflets targeted to reach the places where young men congregate. To be successful, such a campaign would need the support of celebrities such as sports stars to reach young people and point out that it is good to talk about emotions and feelings.
Every area in the country needs a telephone Helpline, which people with mental health issues can ring for advice and support. Posters should be placed prominently by suicide hotspots such as bridges, railway stations and railway lines giving a number for would-be suicides to call and obtain help. Addressing the risk of suicide needs the involvement of a wide range of agencies, including the rail companies, the police, local authorities, Samaritans, mental health services, primary care and youth and community organisations.
Similar mental health promotion and suicide prevention work needs to be carried out with other particularly vulnerable groups, such as asylum seekers and members of some black and minority ethnic communities.
This targeted campaign should also be accompanied by more generic anti-suicide initiatives.
Primary care services
One alarming trend within primary care that the PCTs must reverse is the discrimination that people with mental health problems encounter from GPs. Better training is needed for all staff working in the primary care setting to help them screen, recognise and anticipate someone suffering with mental health problems.
Recent publicity has highlighted the over-reliance of GPs on prescribing anti-depressants such as Seroxat and Prozac. Whilst medication has a place, better provision of counselling, psychology and complementary therapies free at the point of use within primary care and community settings will promote better mental health and well-being.
Also, GPs are notoriously poor at signposting patients on to services such as self-help groups and those provided by voluntary organisations.
A much-neglected area is the need for physical health checks for people with severe and enduring mental health problems.
Other valuable services needed within primary care include Citizens’ Advice Bureau staff, gateway workers and professionals with specific expertise in mental health matters. Work should also be undertaken at a local level with black and minority ethnic communities to identify, plan, commission and deliver services tailored to their specific needs.
Mental health must figure more highly in primary care budget priorities. It is known for patients discharged from hospital, including those diagnosed with schizophrenia, to have requests for a-typical medication rejected on financial grounds. Anyone experiencing mental health problems should be able to have the drug of their choice, and monetary concerns should not be placed ahead of clear clinical needs, thereby compromising treatment.
Discrimination
Government talks about people taking responsibility for the choices they make. However, before people with mental health problems can take responsibility for themselves, government must tackle the discrimination that they face around areas such as poverty, housing, employment, benefits, harassment and violence in their local communities, social isolation, access to services, amenities and educational opportunities and life generally lived in fragmented and deprived communities.
The workplace
Government needs to work with the trades unions, industry and national and local voluntary organisations to educate and help employers recognise the significance of mental health issues for their workforces. This should involve both employees with existing mental health problems and preventing mental health problems developing in other employees, such as work-induced stress, and drug and alcohol habits.
Also, people with mental health problems still face discrimination when applying for jobs. Government must work with the new Equalities Commission to strengthen the Disability Discrimination Act.
Conclusion
The SHA commends the government for acknowledging from very start that addressing inequalities in health is a major political priority.
A significant number of the proposals put forward in this response are evidence-based and have been demonstrated to be successful. The SHA hopes that they will receive serious consideration, and it urges government to be bold and imaginative in the forthcoming public health White Paper.