HEART OF MERSEY

  Heart of Mersey (HoM) is a cardiovascular disease (CVD) prevention charity primarily funded by the primary care trusts and local authorities across Greater Merseyside. HoM aims to co-ordinate a strategic approach to preventing the high rates of cardiovascular disease and associated inequalities in Greater Merseyside. Heart of Mersey is working to achieve its aim through advocacy, campaigns, information and research. HoM works in partnership with a wide range of partners to achieve its aims.

  HoM focuses on improving nutrition and reducing the harm from tobacco as the key modifiable lifestyle factors in reducing not only CVD but other noncommunicable diseases such as cancer, diabetes and chronic respiratory disease.

  Greater Merseyside suffers disproportionately from health inequalities with deaths from CVD around 25% higher than the average figure in England.

EXECUTIVE SUMMARY OF SUBMISSION:

  Heart of Mersey believes that the NHS must engage with other organisations—such as local authorities—in order to address health inequalities. A population-based approach to prevention is more effective than focusing on a number of individuals at high risk of poor health. The role of government in tackling health inequalities is critical as appropriate legislation is essential to support the development of healthier environments where healthier lifestyle choices are made easier. Marketing campaigns which focus on changing the lifestyles of individuals in isolation, are likely to increase health inequalities. The development of the government's stewardship role (Nuffield Council on Bioethics) is encouraged.

1.   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government;

  1.1  The NHS has a limited capacity to directly contribute to reducing health inequalities, as its focus is primarily on treating patients. However, the sections of the NHS (such as within primary care trusts) which are dedicated to public health, health improvement and health promotion have a key role to play in supporting wider efforts to reduce inequalities through advocacy and forming effective partnerships with other key partners such as local authorities through effective local area agreements.

  1.2  In addition legislation has been shown to be a powerful tool to bringing about effective behaviour change which can improve health, for example the seatbelt legislation, and more recently, smokefree legislation in the UK. Achievement of comprehensive smokefree legislation—ie without exemptions for places that may have left more deprived communities unprotected—though the Health Act in England demonstrated that the NHS working in partnership with other public sector bodies, community and voluntary groups and businesses is critical to effect policy change at a population level that will not widen inequalities.

  1.3  Similarly, relevant parts of the NHS must be actively involved in advocating for legislation to support policies which will support improvements in lifestyles, particularly among the more disadvantaged sections of the population. Policies that now require this approach include:

—  The Common Agricultural policy in Europe, which, through its influence on food production, availability and prices in Europe, and has contributed to the widespread availability and consumption of cheap saturated fat in the form of excess beef and dairy products. It has also led to subsidies for the cheap disposal of surplus products such as butter and full fat milk to schools. This policy needs to be revised to support production of health-promoting foods and unsaturated fats, consumption of which will contribute to a reduction in poor diets (FPH 2007). The Department of Environment, Food and Rural Affairs (DEFRA) should also be encouraged to do its bit to support this agenda and strengthen the links and partnership working between agriculture and health for the good of the UK population.

—  The Healthcare Commission's assessments of NHS trusts should include specific targets on local food procurement, provision of health-promoting food to staff and patients, as well as other opportunities to promote healthier lifestyles.

  1.4  The NHS should be willing to engage with the Third Sector—where appropriate—both in the delivery of services but also to seek to influence key sectors with transport, housing and education for example.

2.   The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities;

  2.1  In Cheshire & Merseyside, a guide for practice based commissioners has been produced to improve outcomes in cardiovascular disease. This should impact on the quality of GP services and help to address health inequalities in clinical management for patients with CVD for example.

  2.2  Smoking is a major cause of premature death and ill health. The links between smoking and cancer, heart disease and stroke are well documented. Merseyside in particular has some of the highest smoking rates in the country, particularly in the most deprived communities. GP services are important in the provision of and referral to Stop Smoking Services. The Quality Outcomes Framework (QOF) already makes provision for GP practices to support smokers to quit, with attached payment. Ensuring that GP services identify smokers and offer referral stop smoking interventions, be this practice based, community based or telephone, and that those services are appropriate and easily accessible, is essential.

3.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective;

  3.1  Reducing income inequalities and addressing relative deprivation is likely to be effective in reducing inequalities in CVD. The focus should be on restoring opportunities and reasons for optimism for the whole of society, including the poor and socially excluded. Social, economic, health and environmental policies need to be fully integrated, and economic policies—such as regeneration—must take account of their health implications.

  3.2  Engagement with the "non health" parts of the public sector to enable them to appreciate their impact on health and wellbeing is essential eg, housing, planning etc. Health impact assessments should be applied to major planning applications and infrastructure changes such as road builds or improvements.

  3.3  Appropriate legislation can be a cost-effective and effective mechanism for tackling inequalities. Relevant legislation required includes:

—  A comprehensive pre-9pm watershed ban on advertising on unhealthy products to children. The current ban introduced by Ofcom is a start, but does not go far enough as a large proportion of children remain unprotected at present (Hastings et al 2003).

—  A Common Agricultural and Fisheries Policy as stated previously, which supports and promotes the production of health-promoting foods in Europe and the UK, such as fruit and vegetables, fish, unsaturated oils such as olive and rapeseed oils which are good for the heart, and grains and cereals for human consumption (FPH 2007).

—  Legislation to promote the adoption of traffic light food labels by all food manufacturers. The traffic light system has consistently been shown to be the preferred system of labelling among people from more deprived backgrounds (Food Standards Agency www.food.gov.uk). However, so far, uptake of the system has been led by the retailers with a more affluent clientele such as Waitrose and Sainsbury's, while budget supermarkets which are popular with people from more deprived communities such as Aldi and Lidl have not adopted the system.

—  Comprehensive nutritional standards for food provision in the pre-school sector is needed, in a similar way to the standards which are currently available for primary and secondary schools. In addition, the National Health Schools Programme should be likewise extended to pre-schools. The current lack of action for the improvement of diets of children in this age-group is a missed opportunity to shape the diets of young children from an early age (HoM 2006).

  3.4  Interventions to engage with smokers in Merseyside and support them to quit have more recently included integrated social marketing approaches to support behaviour change. There is real potential for this type of public health approach to engage with deprived communities. In particular, Knowsley and Liverpool PCTs, where smoking prevalence and deprivation are high, have been leading the way nationally in the use social marketing techniques to target audiences and provide tailored services and their four week quit rates have demonstrated the success of this approach.

  3.5  We believe that an upstream population-based approach (McKinlay 1998) is the most cost-effective for addressing and reducing CVD prevalence and health inequalities. The downstream approach, whilst beneficial and effective for patients with recognised CVD, evidence indicates that this medical approach is responsible for a surprisingly small proportion of CVD deaths that occur in the total population (Unal et al. 2005). Furthermore, evidence exists that this is not a cost-effective method for reducing CVD prevalence (Kaplan & Ong 2007; Daviglus et al. 2006). Large reductions in CVD prevalence can be achieved only by a reduction in the population levels of multiple risk factors and this requires a "population-based approach". However, in order to provide "communities" with the opportunity to make changes in their lifestyle to reduce risk factors, it is necessary to have a supportive environment and public policies (both directly related to health affecting the wider determinants) to enable the "healthy choice to become the easy choice" (Rose & Lewis 1991).

4.   Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective;

  4.1  Heart of Mersey itself is an example effective collaboration in Greater Merseyside (Lloyd-Williams 2008). Originally funded by the Merseyside Health Action Zone (along with the Cheshire & Merseyside Public Health Partnership), Heart of Mersey represents a population-level strategic approach to address the high levels of cardiovascular disease in this region. The programme is principally funded by the five primary care trusts and six local authorities of Greater Merseyside.

  4.2  The Cheshire & Merseyside Public Health Partnership (ChaMPs) Social Marketing Group's work in Sure Start areas working with younger children to encourage greater consumption of fruit and vegetables is of interest.

5.   The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

6.   The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meets its Public Service Agreement targets for reducing inequalities; and

  6.1  The successful implementation of smokefree legislation provides a good example of how the Department of Health can work with other departments in co-ordinating policy change. However this cross-department working must now be demonstrated in other areas which will impact on reducing inequalities, for example in developing strategic partnerships with HMRC, DWP and others in the new challenge of reducing availability of counterfeit and illicit tobacco. Without a comprehensive approach to this issue, efforts to reduce smoking in routine and manual worker groups will be undermined because smuggled and counterfeit tobacco is cheap and often perceived as a "Robin Hood" enterprise. There remains much work to do on this complex issue and cross-governmental leadership would improve prospects for success.

  6.2  Similar arguments can be made in the importance of DH and DeFRA working together in essential reform of the Common Agricultural Policy to reflect public health concerns—see 1.3 and 3.3 above.

7.   Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

  We do not believe the PSA targets will be met on current predictions. However with sustained investment in the most successful targeted and population level public health interventions to date, we believe progress can be accelerated. In this respect I would urge the committee to consider:

1.  Heart of Mersey's work as an excellent example of a population level advocacy organisation providing up-stream activity;

2.  PCTs within Merseyside who have developed innovative ways to address the health inequalities challenges;

3.  The importance of the government developing its stewardship role (Nuffield Council on Bioethics 2007) to provide an appropriate environment for healthier lifestyles which includes the development of legislation where appropriate in order to better address its targets in respect of health inequalities.

January 2008

REFERENCES

  Daviglus ML, Lloyd Jones DM, Pirzada A. Preventing cardiovascular disease in the 21st century: therapeutic and preventive implications of current evidence. Am J Cardiovasc Drugs 2006;6(2):87-101.

  Faculty of Public Health. 2007. A CAP on Health? UK Faculty of Public Health. www.fph.org.uk

  Hastings G, Stead M, McDermott L, et al. Review of Research on the Effects of Food Promotion to Children. Glasgow: University of Strathclyde Centre for Social Medicine, 2003.

[www.foodstandards.gov.uk/healthiereating/promotion/readreview].

  Heart of Mersey. 2006. Nursery food provision, policy and practice across Cheshire and Merseyside. Report of a survey of food provision in nurseries across Cheshire and Merseyside to support the Big Noise social marketing project.

www.heartofmersey.org.uk

  Kaplan RM, Ong M. Rationale and Public Health Implications of Changing CHD Risk Factor Definitions. Annu Rev Public Health. 2007 Jan 12; [Epub ahead of print].

  Lloyd-Williams F, Capewell S, Ireland R, Birt C. Delivering a cardiovascular disease prevention programme in the United Kingdom: Translating theory into practice. European Journal of Public Health. Accepted for publication (2008).

  McKinlay JB. Paradigmatic obstacles to improving the health of populations: implications for health policy. Salud pública Méx. [online]. 1998, vol. 40, no. 4 [cited 2007-01-17], pp. 369-379. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0036-36341998000400010&lng=en&nrm=iso. ISSN 0036-3634

  Nuffield Council on Bioethics, 2007. Public health: ethical issues. London: Nuffield Council on Bioethics.

  Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention. BMJ. 2005; 331(7517):614.