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Socialism and Health, the magazine of the Socialist Health Association Spring 2008 This year is the first for many years when members have been offered a choice of candidates for Chair of the Association. You will find statements from the candidates on pages 6 and 7 and a ballot paper should be included in the mailing. Please post it back to arrive at the office by Friday 7th March or bring it with you to the AGM in Wesley’s Chapel on Saturday 8th March.

Inside this issue: Scientists rule!

2

Democracy in the NHS

3

View from the heart

4

David Pickersgill

6

Brian Fisher

7

Access to Primary Care

8

Unequal from the start

9

Health Behaviours and Mortality

13

Future events

14

Elected Members of Central Council Secretary: Huw Davies Treasurer: Gavin Ross Central Council: Dr Clare Bambra, Derek Marcus, Dr Neil Goulbourne, Dr Paul Walker, Tina Funnell, Dr Brian Fisher, David Pickersgill, Gavin Ross, Huw Davies, Mike Roberts, Dr Tom Smith, Dr David Joselin, Sally Young, Dr Doug Naysmith MP, Dr Dianne Hayter, Dame Jane Roberts, Seton During, Melanie Johnson, Ged Taylor, Suresh Pushpananthan, Vivien Giladi West Midlands: David Mattocks and Chris Bain.

London: Patrick Vernon, Tom Fitzgerald, Huw Davies,& John Lipetz Scotland:Ali Syed and Dave Watson Wales: Dr Eddie Coyle and Tony Beddow North East: Lewis Atkinson Unison: Christine Durance.

Unite: Barrie Brown www.sochealth.co.uk

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Scientists rule!

Paul Walker, Chair

I was struck the other day by something the recently retired Government Chief Scientist, Sir David King, said to the effect that he had been surprised and considerably hampered in doing his job by the scientific illiteracy of most Ministers and senior civil servants. My first thought was that we had never had a scientist prime minister and few if any in the higher echelons of government. But of course I was wrong in one respect. For Margaret Thatcher was a scientist – an Oxford graduate chemist if I remember aright. Only Lord (CP) Snow comes immediately to mind in terms of scientist Ministers.

I have to declare a personal prejudice. I had the great good fortune to go to an excellent LEA grammar school whose headmaster was a physicist by background. His policy was that the brighter pupils were strongly encouraged to do sciences with only the less able permitted to do arts subjects. Dutifully, I pursued sciences and developed a clear bias in their favour. This was reinforced at University where, once again, the brighter undergraduates seemed to be those reading science though there was a prevalent heresy that whilst reading history or English was a real education the pursuit of science constituted merely a vocational study!

Not surprisingly when I attended a class reunion recently there were only engineers plus a sprinkling of doctors and teachers.

No bankers, media types or lawyers.

In the 1950’s there was a great debate led I

think by the said CP Snow about the two cultures. The view seemed to be that the grammar school and public school systems were breeding two separate races who had difficulty in communicating with each other. The level of concern was great enough to provoke headmasters like my own to introduce so called general studies subjects into our sixth form curriculum to try to add a patina of “culture” to us scientists. Looking back I do not recall the arts types having to do extra “scientific” subjects to make them more “balanced” individuals which rather suggests that the main worry was of producing philistine scientists by the shedload rather than scientifically illiterate arts types. How things have changed. Now we seem to be producing increasing numbers of scientifically illiterate arts graduates many of whom find their way – as they always have – into the civil service and politics.

In an age of declining scientific literacy in this country, we need to raise the profile of science. The Public Understanding of Science movement is a step in the right direction but we also need to increase the number of scientists in government and among our democratic representatives. Apart from the intellectual rigour and scientific understanding that they would bring to bear wouldn't it be a refreshing change to listen to people schooled in the art of communicating to inform with precision rather than to bamboozle and obfuscate? Whatever her faults, and they were legion, Margaret Thatcher did not waffle. She knew what she wanted to say and she said it with great clarity and brevity. The prevalent practice today seems to be to say nothing at great length; words, words, words, signifying nothing. Evidence to my mind of flabby thinking untutored in the fact-based rigour of science.

What I wonder would CP Snow have said today?

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Democracy in the NHS Gavin Ross

The SHA has long campaigned for a democratically accountable NHS at local level. But what this means in practice is by no means clear. When unpopular decisions are made we ask who it is that makes the decisions, how were they appointed, and what interests they may have that might influence the decisions.

Apart from local councillors there is no tradition in Britain for public elections of local officials or members of boards. Compared with the USA where large slates of candidates are to be voted into public office at the same time as congressional elections, we have no history of this kind of democracy. It is also assumed that few people know or care enough about any of the candidates until things go badly wrong, and that there is anyway a shortage of suitable talent to fill these posts, and that it is important to have knowledgeable specialists rather than local politicians with little experience of the complexities of health administration. If, for example, democratic elections were to be held, say every four years at the same time as County or Regional elections, there is every likelihood that candidates would be selected by political parties and that the results would reflect the political majority of the area. The idea that unpopular decisions would be avoided because those elected feared the consequences is hardly credible. However, that does not mean that we should not continue to press for elected representatives on boards, backed by effective publicity and debate on the issues involved.

Apart from the ability to choose representatives to boards, democracy can also mean the right to influence decisions on particular topics. At present this is done formally by

announcing draft proposals on which comments are invited from the public during a reasonably long consultation period. Informally this is done by meeting with and writing to selected interest groups such as the BMA, the unions, local authorities and Friends of Hospitals, possibly even remembering the duty to consult with Patient Forums or their equivalent. Outside this process the public and political parties may take up the issue and organise petitions, demonstrations and protest letter campaigns. In a sense people would like a referendum on decisions they care about, rather than the chance to replace one set of representatives by another set. Democracy, therefore, means honest consultation and full explanation of the factors influencing any controversial decisions.

Much of the day-to-day administration and small decision-making is of little interest to anyone beyond the few people concerned, and the public are content to leave this to the professionals or to those few selfappointed volunteers who attend meetings and comment on proposals. If there is extra money, everyone is pleased and there is little public debate about where it should be spent. It is only in the climate of cuts and closures that people demand a say in the process. The most difficult cases are where the professionals believe that concentration of services in centres of excellence is necessary, whereas the public believe that closure of an older local hospital is a loss of service if they have to travel further to a more modern facility.

So while the SHA is asking for a democratic health service, we need clarity about exactly what this will entail.

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View from the heart Dr A P Fitzpatrick Consultant Cardiologist Manchester When first established in 1948, the NHS was to provide free health services from a redistributive income tax policy, irrespective of patients’ ability to pay, “in place of fear” of costs that patients couldn’t pay during ill-health.

The desire to reform the UK healthcare system is paralysed by fear of political ruin engendered by a perceived threat to universal coverage.

In fact, numerous examples now exist of healthcare systems in the developed world that perform far better than the NHS, and provide; universal coverage, safe access to care for the vulnerable, no waiting lists and a minimum of political interference.

managers, imposition of elective care targets which crowd elective patients into the space and resources previously used for the sickest patients, and much conflict. Hardly a week passes without a new medical technology or technique being announced, and more and more money must be raised in order to preserve the fundamental principles of the NHS. Now the UK has the world’s 29th best healthcare system, and productivity is falling.

In the summer of 1991, I averaged 135 hours a week for 6 weeks. The fatigue was great, but the experience was greater. District referrers were happy with the service, which seemed to provide tax-payers with excellent value at very low cost. It seemed that Bevan’s objectives were being met, “my job is to give all the facilities, resources, apparatus, and help I can, and then leave you alone as professional men and women to use your skill and judgement without hindrance”.

New contracts for GPs and hospital doctors were drawn up without any attempt to assess what work they were already doing, and consequently, these contracts cost £450m more than anticipated, leaving little money for service improvement. New hospital buildings were ordered with costly borrowing schemes just as revenue was being diverted into independent hospitals and the government was calling for more care outside of hospitals. It is hard to escape the view that government should have taken Bevan’s advice and left us to get on with the job.

Patients need more choice, and the service needs to be more client orientated.

The last 10 years has been very different. There has been unprecedented growth in funding, unprecedented interference in the delivery of care by politicians and

In the first 10 years of my career we provided excellent care for the sickest patients first, at low cost. But very long elective waiting times, unheard of in other

Western European countries, were inevitable. A taxpayer with an elective illness deserved better. However, the NHS answer to this has been to create multiple tiers of staff to choose on a patient’s behalf, not to give a patient portable healthcare entitlement with which they can choose for themselves. As a consequence, the client and the service are disconnected.

One agency pays for care, another allocates it, a third prescribes it, and the patient receives it. Small wonder that the final service may not be what the client was hoping for. However, they cannot complain, and they cannot take their custom elsewhere. We still have an irrational system of delivery that separates client and service.

On the supply-side, much hope is being placed in competition between providers, public, independent and private. However, healthcare requires efficient vertical integration of primary, secondary and tertiary care to work well. What is being created is vertical competition between providers of different levels of care, along with horizontal competition between providers of similar care. This is a damaging free-for-all. To use a sporting analogy, two football teams take the field to compete, but to be effective, the defence, midfield and attack need to work together to overcome the op-

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position. The competition being fostered in the NHS pits one team against another, but in each team, the defence, midfield, and attack are also competing for the ball. GPs see district hospitals sucking in resources that they could use more effectively, district hospitals see tertiary centres and want to emulate them. Instead of NHS competition creating efficiencies, it creates waste.

UK healthcare needs radical thinking to correct the structural problems afflicting the demand for, and supply of healthcare services. Universal coverage is taken for granted in the 28 countries above us in the healthcare league, and is not negotiable here. It is difficult to see how patients can genuinely exert demand-side choice pressures on the system without some kind of portable cover that they can use as an individual, independent of layers of expensive bureaucracy to make decisions for them. Such clientchoice should shake providers out of complacency.

However, providers will be

limited in their ability to create economies of scale, and efficiencies in delivering care, unless they have natural allies in the carepathway. For district hospitals to compete for patients with GPs and tertiary providers makes no sense, but the system being developed encourages this.

Far better for primary, secondary and tertiary providers to be allied together against similar organisations, competing for patients with a portable healthcare cover. Bureaucrats engaged in choosing care for a patient would be much better employed in streamlining collaboration between providers in vertically integrated care pathways.

Politicians urgently need to grasp these principles. If they cannot, or will not, then an independent commission should be allowed to plot a course for the future. If changes are not made then taxes will rise inexorably, or free universal coverage will be sacrificed.

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David Pickersgill: Statement in support of nomination as Chair of Socialist Health Association

About me …

I have been a member of SHA for around 20 years and of Central Council for around 18. I am currently a Vice Chair. My decision to stand as Chair was in response to requests from senior Central Council members that I consider doing so.

For people who do not know me my work roles are as a community mental health nurse and trade union activist. I’m an RMN and Specialist Practitioner, have a first class BSc in Community Health Nursing and currently do clinical work two days per week with the Crisis Resolution Service for working age adults in Wakefield.

The rest of my working week I’m Branch Secretary of a medium sized (just under 2000 members) UNISON health branch with Mental Health Trust, PCT / other primary care and voluntary sector membership. I sit on the Yorkshire & Humberside Regional Committee of UNISON as one of two representatives from health branches. A few years ago my trade union work led me to seriously contemplate a change of career to law and I completed both the Common Professional Examination and Legal Practice Course, but eventually decided I preferred my current career in the NHS.

In party terms I have been a Labour Party member for 25 years this year, and early last year was elected as Chair of the re-organised Wakefield CLP. I have previously been District Party (LGC) Chair, Labour Group Observer, agent, council candidate in an un-winnable seat, etc..

monly to people with complex and multiple needs. Improving this care requires greater cooperation between providers, not competition, as does both the development of clinical knowledge and maintenance of professional standards in high tech hospital settings.

My vision for the SHA:

I’m also enough of a 1980’s leftie to believe that the NHS is not only the state provider of health care, but a - far from perfect - living example of what socialism is about: collective organisation to meet people’s needs irrespective of their ability to pay, making us all better off as citizens of a fairer and safer society as a result..

In all the activities I have outlined above I have found the SHA to be an incredibly stimulating resource, helping develop my thinking about health, NHS and general political / Labour Party issues.

We are a rather unusual space where people with very diverse backgrounds can come together to address common issues and interests. This is our ‘unique selling point’. Where else can politicians, health professionals, patient advocates, trade unionists, health planners and academics, NHS board members (and even the odd member of the public) come together on equal terms? I feel strongly we need to both retain and promote this feature of the SHA. Politically I am opposed to the current government initiatives to introduce competition and a greater role for the private sector in the NHS – so called marketisation. Most health care is delivered in primary and community care settings, com-

I hope you will consider supporting me. I am also a candidate to remain a Vice Chair.

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Brian Fisher Statement in support of nomination as Chair of Socialist Health Association

The future of the SHA and the NHS We have a chance to shape the NHS. Labour has achieved a lot - but is now uncertain. Current plans are neither popular nor delivering. The SHA must propose a practical socialist programme and continue to campaign for it, merging ideas, logic and emotion. We need to fuse: • the founding principles of the NHS, • the commitment of the population to the ideals of the NHS • concrete, workable evidence-based, socialist plans • a commitment to an NHS that listens to, responds to and is respectful of both communities and individuals. The emotional side of the NHS is key.

• a refutation of the market base of the current programme.

John Lipetz, Paul Walker and I have helped to write such a document which will be used as a basis for SHA programmes and campaigns. We need to raise the profile of the SHA to achieve influence. To build on our history, experience, friends and contacts. We need to ensure that the government hears these radical but sensible ideas. We need to take them to the public in a way that builds consensus and confidence. A public face carries risks, but we have the experience and the capacity to do it well.

So, if I were chair, I would encourage us to: • learn from other groups such as Compass, other parts of the UK and internationally • focus on involving patients both in their own care and in designing and developing improved approaches to care. I would advocate a national debate on accountability • develop non-marketised, non-competitive approaches to commissioning and planning • offer a clear, evidence-based, practical programme for prevention, public health and reducing inequalities • develop a clear programme for involving staff in improving services

About me A London GP since 1976, I will reduce my clinical work soon, allowing more time for the SHA while remaining in primary care. I am involved in day-to-day NHS politics: I am on the Lewisham PCT Professional Executive Committee and the PCT-wide practice-based commissioning federation.

As Patient and Public Involvement lead for the NHS Alliance I have brought our two organisations together. I have worked with and been consulted by the DH, Connecting for Health, Lord Darzi, the Healthcare Commission. I have links with national voluntary agencies and primary care. I regularly publish research.

Although a new member of the SHA, I have influenced our development. My roots are not in the traditional Labour movement but I have been a union member and socialist throughout my career, expressed through active community development work and a commitment to patient and citizen accountability, with publications on these topics. After years of experience of record sharing with patients, I have set up a company enabling patients access to their full GP record online. This will transform care.

Chairing committees in the voluntary sector, PCT, Health Authority and national level, my leadership comes through working cooperatively and building on mutual strengths. I take decisions when needed and like to get things done. I have a track record of achieving practical improvements in the PCT, in patient and public involvement nationally, and in the field of IT. I want the SHA to make a difference – to impact on the thinking, the feeling and the doing of the NHS. We can build the organisation, make a real impact – we have the links, the ideas and the leadership

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The case for greater access - SHA press release The BMA fought tooth and nail against the establishment of the National Health Service and some of our members still remember that campaign. They now claim that opening three extra hours a week will lead to the end of the NHS. We find the logic of their position hard to follow.

A substantial minority of patients find it difficult to access primary care services. Problems about access have not been cooked up by Gordon Brown. They are not just about extended hours, although that is a real issue in places where there is widespread commuting.

Plenty of practices have poor access arrangements, some because of efforts to comply with the 48-hour target. People in low paid jobs find it difficult to get time off to attend a GP. Manchester Health Watchdog completed a survey of patients' experience of general practice last month.

Most reported an excellent service, but some of the stories were terrible. Eighty per cent report that they have to ring the GP practice first thing in the morning to make an appointment. Not everybody can do this:

"I just cannot get an appointment!" reported one patient. "I hang on the phone for up to half an hour and then I have to go to work. I ring later and am told there are no appointments left and I have to ring back next day. They do not allow you to book for one or two days hence, you have to ring on the same day. It is a nightmare. Once the doctor asked to see me in a week's time. I tried for three weeks to get an appointment and then wrote to the doctor explaining why I hadn't returned to see her."

The BMA are worried about the possibility of big corporations providing a poor service for less money. Their claims would be more convincing if they were more concerned about poor standards in traditional self-employed general practice. Large corporations are not likely to offer a better service, but GPs are also undermining the traditional model of primary care. Many practices employ salaried doctors, partnerships are getting hard to come by, and some traditional practices seem happy to set up satellites and staff them with locums.

We support the idea of

practice flexibility to meet the needs of people who find current opening hours difficult.

The government needs to recognize that providing these services may mean more costs to primary care: to ensure enough cover for staff in the extremes of the day to ensure adequate diagnostic and backup facilities to make those extremes useful to patients.

Many GPs work very long hours. But opening the surgery for three extra hours a week is not an impossible burden. We don't like Brown's rhetoric when he says "you should be able to see your doctor when you want to".

People should see the health professionals they are seeing as people - not as distant figures to be deferred to in the old model, not as servants either, but as partners. This is an issue which should be decided locally. Needs for access in Penge are not the same as needs in Penzance. Access is not just about doctors.

Some people who want non-urgent appointments out of hours really need a nurse.

Most people have little information about the availability of walk-in centres and other facilities which might meet their needs.

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Unequal from the start: How can we give babies a fair chance of health?

Report from an SHA policy seminar London Tuesday 22nd January 2008

Inequality in health is at its This document will form the ba- political situation in the UK, in most pronounced around sis of an SHA submission to the particular the leverage exthe time of birth. Our gov- Labour Party National Policy Foerted by a small number of ernment is committed to rerum, and we would welcome middle class voters in a few ducing health inequality in comments from members. middle class constituencies, the population and is devotmakes talk about redistribuing considerable resources tion very unwelcome amongst politicians who to the problem. Has the Socialist Health Ashave to face the electorate. Political leadersociation any new ideas to contribute? This ship which is capable of making a coherent paper attempts to consider issues around and convincing case for a more equal society inequality from before birth and in the first has not emerged. Although there are many year of life. politicians in all parties who appear to genuinely espouse the idea of redistribution none Infant Mortality have managed to resist the pressures from the The infant mortality rate among the “Routine articulate middle classes to, for example, reand Manual” group was 17% higher than in duce the burden of inheritance tax. the total population in 2004-06, compared with 18% higher than in the total population There is little absolute poverty in the UK other in 2003-05, and 19% higher in 2002-04. This than the destitution which is used as a political compares with 13% higher in the baseline weapon by the government against asylum period of 1997-99. So it is clear the target seekers. Those failed asylum seekers, who for reduction of this difference is not going to are literally destitute, are of course often of be met by 2010 unless something more is childbearing age, and may make a decision done. that it is better for them and their families to be

Wider determinants of health The most fundamental issue, which neither the Labour Party nor the Government cares to discuss is whether individual focussed efforts to improve behaviour have any chance of success when the wider causes of inequality are not confronted. The work of Sir Michael Marmot and Richard Wilkinson demonstrates very clearly that inequalities of wealth and income even among people who are not in any normal sense of the word “deprived” have a very strong influence on the health of the population and life expectancy. The other side of this debate, which some people in the public health community don't seem to want to discuss, is what can be done to counter these powerful forces in the short term.

We remain convinced that a programme of redistribution of wealth along the lines which have evolved in the Nordic countries would do more to improve the health of the population than any other measures. However the

destitute in London than in Mogadishu or Harare. We are not convinced that the decision to withdraw both support and free medical care from this group is rational from the perspective of the tax payer. If their babies end up in paediatric intensive care, or the mothers die in childbirth that will cost a great deal more than will be saved by denying them primary care. However this problem raises much wider questions than can be dealt with here.

There is, however, a great deal of relative poverty in the UK, and its burden falls particularly on those of childbearing age. The weekly rates of means tested benefits for a person aged 16-17 are £35.65, for a person aged 18-24: £46.85. For people over the age of 60 the rate is £119.05 a week. Rates of payment for those supported by the National Asylum Support Service are about 70% of that. It is hardly surprising that some of these young people are socially excluded and live unhealthy lives.

Of course it would be better if they were working or studying, but there are often reasons which make these ambitions difficult to realise, and pregnancy is one of them.

Reducing inequalities in the population, even if it is attempted, will take time. Globalisation makes the problem of inequalities far more difficult to tackle. So in the short term at least we need to focus on initiatives which are more politically acceptable.

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Evidence of what works The Combined Impact of Health Behaviours and Mortality in Men and Women: The EPICNorfolk Prospective Population Study seems to provide a quite convincing basis on which health intervention at the level of individual behaviour could be evaluated.

These findings indicate that the combination of four simply defined health behaviours predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. They also show that the risk of death (particularly from cardiovascular disease) decreases as the number of positive health behaviours increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be confirmed in other populations and extended to an analysis of how these combined health behaviours affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. Armed with this information, public-health officials should now be in a better position to encourage behaviour changes likely to improve the health of middle-aged and older people. (Public Library of Science 2008) This important study was conducted among middle aged people and clearly does not apply directly to young women. But it would be very surprising if the same factors (smoking, drinking, diet and exercise) did not affect younger people and if the multiplier effect did not apply to them.

Policy issues 50% of conceptions are unplanned, so it is difficult to identify which women are (or may soon be) in early pregnancy. There are many valuable interventions which can be undertaken with different groups to address aspects of early pregnancy, eg alcohol consumption,

Page 10 diet, smoking. We need to develop more creative approaches to promoting good health in pre-conception and early pregnancy.

Teenagers, especially girls, need a diet rich in calcium and iron, but they often don't have one. Problems relating to body image are critical at this time in a woman's life, and of course relate chiefly to self esteem and the behaviour of boys. Messages from health professionals are drowned out by commercial and social pressures to conform.

Young mothers tend to present late to maternity services. We need to try to make services more welcoming to them and more relevant to disengaged young people.

We need a longer period of paid maternity leave, a significant extension of paid leave for fathers/partners, and the right to request flexible working for all parents. Improving rights at work for parents are of little help to young people who are not in legitimate employment, and there is reason to believe that young people are disproportionately affected by vulnerable employment. There is still considerable prejudice amongst employers (and some employees) against women who exercise their rights to maternity leave. In relation to health and safety issues, few employers have a good understanding of their obligations to undertaken and act on risk assessments for pregnant employees and those returning to work within six months of the birth or is breastfeeding. Relying on employees to request a risk assessment and insist on appropriate changes to their work places an unreasonable burden on mothers and is likely to impact on the health of mothers and their babies.

There is a continuing rise in the proportion of births to mothers born outside the UK: 21.9 per cent in 2006. There is a similar rise in the numbers born to BME mothers who were born here. Both the stillbirth rate and neonatal mortality rate are higher in women of Black, Asian or Other ethnicity. Vitamin D deficiency is a widespread problem among BME women.

Healthy Start women's vitamin supplement contains folic acid and vitamin D for preconception, pregnancy and throughout breastfeeding. We think this should be made freely available without charge. The fact that some women have to pay makes it much more difficult to distribute. Given the low cost and high

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benefits we think that everything possible should be done to ensure that the vitamins reach all at risk women.

It is by no means clear that services are always culturally appropriate for BME women.

Nor is it clear that government policy initiatives sufficiently address the position of mothers in BME communities. There has been a lot of talk about choice in maternity services over the last 15 years, but not a great deal of delivery. There is plenty of evidence about the long term costs of low birth weight babies and the effect of maternal deprivation, but the resources devoted to dealing with the problem are not in proportion to those costs.

Measures which are officially promoted – such as nicotine replacement therapy for pregnant women - are not delivered consistently. The most obvious is the promotion of breastfeeding. It is clear that even within NHS organisations the messages about the importance of breastfeeding have not been accepted or implemented. Breast feeding has immensely beneficial effects, but the resources needed to help women to do it are not forthcoming. Another neglected issue is the spacing of births. In other parts of the health service the principle of “invest to save” is well established. Why not here?

There are still problems with social and relationship education, which seems to be handled better in other European countries.

Secondary schools, and parents, are still very anxious about discussing issues relating to sex. It is pretty unclear who, if anyone, takes responsibility for developing life skills in this area. This leads to more risky behaviour among young people. Girls are blamed for “getting pregnant” and boys know little or nothing about issues like breast feeding. Sex education should start much earlier, in primary school, and the idea that it is an optional extra for schools must be abandoned. The country in Europe

with the lowest teenage pregnancy level is Holland – the country which starts sex education earliest..

Training in diversity for health staff does not extend to issues relating to poverty, and many well meaning health initiatives fail because social issues (such as the importance of territory on housing estates) are not taken into account.

Government Initiatives 1.Support for families through Children's Centres: currently over 1,750 centres are open, with 2,500 planned for 2008 so that all the most disadvantaged areas have a centre, with 3,500, one in every community, by 2010. Will these centres just provide childcare, or will they address other needs?

2. Extended schools offer pupils, families and community members quick and easy referral to services, including health services, on and off site and Healthy Schools take a whole-school approach, including parents, to promoting better health through national standards in healthy eating, physical activity, emotional health and wellbeing, and personal, social and health education.

3.Family-Nurse Partnership demonstration sites, - parenting support delivered by

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health visitors can improve life outcomes for young first time mothers and their children. All first-time mothers under and up to the age of 20 are referred to the demonstration sites but the sites aim to focus on the more vulnerable: factors taken into account include age, income, family support and marital status.

that those without clinical training can access specialist support when necessary and those without the benefit of roots in local communities can access that knowledge and experience. The way that public health budgets have been systematically raided to prop up acute services has left the workforce demoralised and disorganised. There should be sensible career pathways in public health. Let’s get rid of the notion that the only peo4.Early identification of at risk families and ple who can join the profession at a level with deplans to make breastfeeding the default op- cent pay, or progress in their careers are those tion for mothers. who have already qualified in clinical work. At present nobody seems to be taking any responsi5.Investment in healthy schools, increasing bility for the coherent development of a public participation in physical activity, and making health workforce. cooking a compulsory part of the national curriculum.

6.A £75 million marketing campaign to support and empower parents to make changes to their children's diet and increase levels of physical activity.

7.£190 the Health in Pregnancy Grant, from April 2009 8.Child Benefit from the 29th week of pregnancy – we would like to see this start much earlier 9.Sure Start Maternity Grant £500 at week 29 10.Healthy Start Vouchers £2.80 per week from week 10

Workforce There are difficulties in the management of the public health workforce. While it is now established that medical qualifications are not required for Directors of Public Health, health visitors are being suppressed as a profession by the Nursing and Midwifery Council, which is insisting that Health Visitors who came through the midwifery route must continue to practice as midwives for 450 hours a year. At the same time spearhead PCTs are being encouraged to employ health trainers directly recruited from disadvantaged communities. This initiative may be productive, but at the same time various public health specialist interventions are being planned. The specialists and generalists need to be formed into coherent teams so

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Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study

Every day, or so it seems, new research shows that some aspect of lifestyle—physical activity, diet, alcohol consumption, and so on—affects health and longevity. For the person in the street, all this information is confusing. What is a healthy diet, for example? Although there are some common themes such as the benefit of eating plenty of fruit and vegetables, the details often differ between studies. And exactly how much physical activity is needed to improve health? Is a gentle daily walk sufficient or simply a stepping stone to doing enough exercise to make a real difference? The situation with alcohol consumption is equally confusing. Small amounts of alcohol apparently improve health but large amounts are harmful.

Why Was This Study Done?

There is another factor that is hindering official attempts to provide healthy lifestyle advice to the public. Although there is overwhelming evidence that individual behavioural factors influence health, there is very little information about their combined impact. If the combination of several small differences in lifestyle could be shown to have a marked effect on the health of populations, it might be easier to persuade people to make behavioural changes to improve their health, particularly if those changes were simple and relatively easy to achieve. In this study, which forms part of the European Prospective Investigation into Cancer and Nutrition (EPIC), the researchers have examined the relationship between lifestyle and the risk of dying using a health behaviour score based on four simply defined behaviours—smoking, physical activity, alcohol drinking, and fruit and vegetable intake.

What Did the Researchers Do and Find?

Between 1993 and 1997, about 20,000 men and women aged 45–79 living in Norfolk UK, none of whom had cancer or cardiovascular disease (heart or circulation problems), completed a health and lifestyle questionnaire, had a health examination, and had their blood vitamin C level measured as part of the EPIC-Norfolk study. A health behaviour score of between 0 and 4 was calculated for each participant by giving one point for each of the following healthy behaviours: current non-smoking,

not physically inactive (physical inactivity was defined as having a sedentary job and doing no recreational exercise), moderate alcohol intake (1–14 units a week; a unit of alcohol is half a pint of beer, a glass of wine, or a shot of spirit), and a blood vitamin C level consistent with a fruit and vegetable intake of at least five servings a day. Deaths among the participants were then recorded until 2006. After allowing for other factors that might have affected their likelihood of dying (for example, age), people with a health behaviour score of 0 were four times as likely to have died (in particular, from cardiovascular disease) than those with a score of 4.

People with a score of 2 were twice as likely to have died.

What Do These Findings Mean?

These findings indicate that the combination of four simply defined health behaviours predicts a 4fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. The risk of death (particularly from cardiovascular disease) decreases as the number of positive health behaviours increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be confirmed in other populations and extended to an analysis of how these combined health behaviours affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations.

From PLoS Medicine January 2008

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