1.  BACKGROUND

  1.1  The Royal Society of Health (RSH) and the Royal Institute of Public Health (RIPH) were established during the mid-Victorian era to promote and protect public health. The two organisations are experiencing a major resurgence at present and will be merging during 2008. They are both Registered Charities.

  1.2  The combined membership of the RSH and RIPH is almost 7,000, comprising practitioners and professionals from all areas of public health. Both organisations are recognised Awarding Bodies by the Qualifications and Curriculum Authority (QCA) and over 100,000 individuals qualify every year through their networks of training institutions.

  1.3  Established in 1999, the NGO Forum has been managed by the RSH since April 2006 under a contract with the Department of Health (DH). The Forum includes approximately 100 national NGOs, comprising of the major health charities (eg Diabetes UK, British Heart Foundation, etc.), professional associations (eg Faculty of Public Health, Chartered Institute of Environmental Health), consumer bodies (eg Which), advocacy organisations (eg UK Public Health Association), NGOs who create practical changes to the built environment (eg Sustrans).

2.  INTRODUCTION

  2.1  All three organisations have a strong interest in inequalities in health. The NGO Forum relates to the DH through the "Health Inequalities" Branch. Members of the Forum are committed to reducing health inequalities.

  2.2  The NGO Forum, with support from the Royal Society of Health, is in the process of establishing a National NGO Plan for Health. The expectation is that this will be launched in approximately twelve months time and will address health inequalities. Many Forum members work closely with NHS bodies and, indeed, receive funding from the DH or NHS to take forward work designed to reduce inequalities in health. The work of the "Third Sector" is directly relevant, therefore, when reviewing the contribution made by the NHS on this issue.

  2.3  The RSH receives funding from the DH to take forward development work with NHS organisations and practitioners engaged in health promotion. In addition, the RIPH has a contract from the DH to provide qualifications for health trainers, many of whom work in or with NHS organisations.

  2.4  All three organisations endorse the Select Committee's view that inequalities in health are determined to a large extent by non-NHS factors, such as housing, fiscal policy, education, and environmental issues. This submission, however, will concentrate on the role of the NHS and the interrelationship between the NHS and the "Third Sector".

  2.5  The RSH, RIPH and NGO Forum support the principles, priorities and actions set out in "Health Inequalities: Programme for Action" (DH, June 2003)

The Actions likely to have greatest impact:

—  improvements in early years support for children and families

—  improved social housing and reduced fuel poverty among vulnerable populations

—  improved educational attainment and skills development among disadvantaged populations

—  improved access to public services in disadvantaged communities in urban and rural areas, and

—  reduced unemployment, and improved income among the poorest

—  reducing smoking in manual social groups

—  preventing and managing other risks for coronary heart disease and cancer such as poor diet and obesity, physical inactivity and hypertension through effective primary care and public health

—  improving housing quality by tackling cold and dampness, and reducing accidents at home and on the road

To close the gap in infant mortality, key short-term interventions include:

—  improving the quality and accessibility of antenatal care and early years support in disadvantaged areas

—  reducing smoking and improving nutrition in pregnancy and early years

—  preventing teenage pregnancy and supporting teenage parents

—  improving housing conditions for children in disadvantaged areas

—Extract from "Health Inequalities: Programme for Action".

    The RSH, RIPH and NGO Forum would welcome an opportunity to provide oral evidence to expand on this succinct submission.

3.  POTENTIAL FOR THE NHS TO MAKE AN IMPACT ON HEALTH INEQUALITIES

  3.1  Although the fundamental determinants of health have by far and away the greatest impact on health inequalities, there is an important role for the NHS to play. This role concerns:

—  Needs assessment and public engagement

—  Access to NHS services;

—  A leadership role for PCTs and Strategic Health Authorities in stimulating partnerships that address the wider determinants of health and inequalities;

—  The NHS commissioning function;

—  PCTs acting as the catalyst for financial investment in deprived areas;

—  The role of the NHS as a provider of technical expertise in areas such as "health impact assessment".

—  Sustainable development—the NHS as a model of good practice

  3.2  Equity of access: The NHS frequently refers to "hard to reach" groups, usually those at greatest risk of ill health. In making such statements, planners are looking down the "wrong end of the telescope". From the perspective of those individuals at greatest disadvantage, we are referring to "hard to reach services"! Whether planning health promotion, prevention, or health care, services should always be developed to meet the needs of the local community, rather than expecting the community to meet the needs (and constraints) of the services. Equity of access is a starting point for reducing inequalities in health.

  3.3  Community assets: All communities have assets as well as needs. Even where there is a comprehensive needs assessment, it is rare for local community assets to be mapped as a resource for better health. Assets can include information networks, opinion formers, local leaders, skills, community organisations, and social networks. We encourage PCTs to undertake an assessment of community health assets, as well as needs.

  3.4  NGOs and local community groups are often best placed to deliver health promotion support to disadvantaged communities, be it increasing physical activity or improving diets. They do not have the "stigma" sometimes associated with formal public sector service provision. NGOs tend to adopt more informal approaches, based upon the natural organisational and communication structures inherent to the community, and are perceived as being less "authoritarian". The NHS has a key role in working with local communities to identify their health needs and aspirations, and subsequently commissioning the services (whether NHS managed or not) which best meet those needs. The NHS does not always take full advantage of the expertise of NGOs, nor develop in-depth and mutually-beneficial partnerships with them.

  3.5  User and community engagement: There are tried and tested ways of community engagement in setting local NHS priorities and in designing local service provision. However many NHS bodies fail to engage successfully with their users and lack expertise in their involvement. The role that volunteering has in improving health is under utilised within the NHS.

  3.6  Strategic partnerships: The overall resources available in a community to tackle health inequalities extend well beyond the NHS. NHS organisations have a responsibility to build "strategic partnerships" in order to make the best use of the community resources available. The NHS has a pivotal role as convenor and facilitator in relation to health inequalities, in partnership with the local authority. In order to fulfil this catalytic role regionally and locally, SHAs and PCTs need to develop the necessary capacity and skills required to build effective partnerships. Feedback from local organisations and practitioners suggests that many, perhaps most, strategic partnerships tend to be superficial, rather than truly productive. This is reinforced by the 2006 National Evaluation of LSPs (Department of Communities and Local Government, June 2007), which indicated that LSPs are still predominantly concerned with process, structures and protocols. Key partners for the NHS include local authorities, NGOs, regional and local media, and higher education institutions.

  3.7  The "commissioning" function of PCTs is usually viewed as being largely concerned with purchasing secondary and tertiary care services. Much more emphasis should be placed on the commissioning of health promotion and disease prevention initiatives, specifically directed at the determinants of health in the most disadvantaged communities. For example, the NHS is a major purchaser of food and could influence the food supply chain by using its economic power to insist upon "healthy" specifications and locally-sourced food. The public sector could fundamentally alter the food chain from agriculture through manufacturing, processing, retailing, catering and marketing, by exercising its economic strength in the market place.

  3.8  Financial investment: NHS organisations are major investors of capital and major employers. In reaching investment decisions, little or no account is taken about how to achieve the greatest heath gain. To give an example, decisions about where to site support services, such as laundry, are invariably taken on the basis of transport logistics rather than the potential for providing jobs in areas of significant unemployment. The potential for health gain by targeting investment to the areas of greatest development need should be given much more emphasis. This will entail a "health impact assessment", which considers the overall health benefit (or cost) of each option.

  3.9  Health impact assessment: Decisions are frequently taken by the NHS and local authorities without a full understanding of their wider health impact. The NHS is best placed to assist in providing the necessary technical expertise to aid not only decision-making within the NHS, but in other public bodies as well.

  3.10  Climate change/sustainable development: There is not the slightest doubt in the eyes of the vast majority of scientists that climate change is real and will have an enormous impact on health over the coming decades. The least well-off suffer most from any major environmental challenge to health. Climate change and, by definition, sustainable development are "inequalities" issues. As such, the NHS should be at the forefront in adopting carbon emission limiting policies, even if this requires an initial injection of capital resources. In due course, such investment would reap a dividend in reduced recurring expenditure. Transport and energy policy, commissioning criteria, and purchasing specifications should all reflect the NHS' commitment to good practice.

  3.11  Dental disease: It is worth adding that dental disease is also a function of disadvantage, poor people suffering more than the better-off. NHS bodies should ensure that they have a clear policy in support of fluoridation.

4.  HEALTH DISTRIBUTION ACROSS THE COMMUNITY—WHERE TO FOCUS?

  4.1  Policies to tackle health inequalities often target the 10% most disadvantaged in the community. Although they are most at risk of poor health, they are numerically small in terms of the overall size of the population. Moreover, identifying the 10% "outliers", without addressing other groups in society, ignores the whole process of social influences on health.

  4.2  A case can be made for targeting a much larger group, say the 35—40% of the population above the 10% most at risk, with additional, intensive action. This would have the dual advantage of taking into account some of the wider social pressures on the health of the worst-off and also address a much larger group of individuals, who are relatively disadvantaged compared to the mean. The numerical impact of this combined health inequalities strategy could well be much more noticeable than merely focussing on the 10% of the population at greatest disadvantage.

5.  CAPACITY, CAPABILITY AND WORKFORCE DEVELOPMENT

  5.1  The ability of the NHS to fulfil its potential in reducing inequalities is dependent on having the right number of people with the right skills deployed in the right way. Feedback from public health practitioners indicates that England has a dearth of appropriately skilled individuals in post. The most recent reorganisation of the NHS appears to have decimated what was already a fragile infrastructure in many PCTs. It is ironic this has occurred just as there is a growing recognition of the importance of health promotion and prevention nationally.

  5.2  In his report to the Prime Minister in 2004, Derek Wanless identified the problems associated with capacity and restructuring:

Much of the workload in the health services in achieving local objectives will fall on PCTs. They are relatively new and small bodies and they have a crucial role in ensuring the NHS delivers, particularly in commissioning and in driving behaviour changes in primary care. Each has a Director of Public Health and this is spreading existing resources very thinly, although there is a welcome move to broaden the skill base by introducing non-medical Specialists. PCTs will be vital in making the new primary care contracts work to best effect, including in public health. Given the newness of the structure and that repeated restructuring has tended to weaken the NHS over decades, structural change is not recommended but where it seems locally that the best way forward is to combine PCTs' forces to tackle public health that should not be discouraged.

—Extract from Wanless report, Feb. 2004.

  5.3  Judging from reports received by the national bodies, the enlarged PCTs appear to have shed capacity rather than improved it. As the Chief Medical Officer has said (Annual Report, 2006), recent public health investment is in line with the "slow uptake" rather than fully-engaged scenarios. The view of the RSH, RIPH, and National NGO Forum is that it is wholly unrealistic to expect any significant impact on health inequalities with the current levels of PCT investment in public health and health promotion capacity.

  5.4  Following publication of the Second Wanless Report (Feb. 2004), the Government made a welcome and strong commitment to public health and the reduction of health inequalities through the publication of "Choosing Health" (DH, Nov. 2004). This included specific "Choosing Health" funding for PCTs. However, the "Choosing Health" monies have been rolled into the overall funding for PCTs and most have deployed their funds to meet other needs. Sexual health and HIV/AIDS services could be examined to see the impact of this under investment. Waiting times and achieving financial balance are still the pre-eminent considerations. This is a major missed opportunity and should be redressed as a matter of urgency. Health inequalities must be given a much more prominent position in the performance management agenda. The RSH is currently piloting a national "Award Scheme" to recognise PCTs and other local organisations that meet a range of criteria, including financial investment and workforce development.

  5.5  "Choosing Health" indicated that the NHS should embrace and capitalise on all the opportunities resulting from the numerous daily encounters people have with NHS.

—  Make the most of the millions of encounters that the NHS has with people every week;

—  Ensure that all NHS staff have training and support to embed health improvement in their day to day work with patients;

—Extract from "Choosing Health".

  This is not happening. Many NHS practitioners do not have the necessary training and skills. There has been a failure locally to "scale up", as identified in the Wanless Report, a whole range of initiatives from Health Action Zones to the Expert Patients Programme. Investment is wasted when it is not of sufficient scale to produce health impact.

  5.6  Some initiatives identified in "Choosing Health" have been taken forward, but are unlikely to be sustained. For example, the "Health Trainers" programme is showing early signs of success, not only in terms of reaching those individuals at higher than average risk of poor health, but also in releasing non-NHS resources. Some 1,500 health trainers are now in place, with several thousand more undergoing training. Our assessment is that we probably need between 50,000 and 100,000 health trainers to make real impact, but it now looks likely that the earmarked funding for the "Health Trainers" programme will come to an end during 2008. As indicated in the Wanless Report, success will be dependent on long term, sustained and targeted investment.

  5.7  Each PCT should have a "Workforce Development Plan" that focuses on the organisation's health inequalities objectives and the skills needed to achieve these. This should include all PCT staff, not just the specialised staff involved in planning and management, and it should also include the "wider public health workforce" in the community, who also need training and development. A "ladders and bridges" approach allows staff to improve their skills over time and according to changing community needs. Universities and NGOs can play an important role in both training needs assessment and in delivery.

  5.8  The "Teaching Public Health Networks" have much to contribute in sharing good practice. We strongly recommend that support for the TPHNs should continue.

6.  THE DEPARTMENT OF HEALTH

  6.1  It would be remiss of us not to comment on recent changes at the Department of Health. In contrast with the situation locally, the DH has given greater emphasis to public health and inequalities, not least through a clear emphasis on workforce development.

  6.2  The recent decision to highlight the importance of health inequalities through the cross Government role envisaged for one of the Deputy Chief Medical Officers is welcomed. So too is the intention to strengthen the DH public health commissioning function, which will enable the DH to have a more comprehensive overview of the support required. Despite the emphasis on workforce development, DH efforts will have limited impact without a similar commitment to invest locally in public health, health promotion, and action to reduce health inequalities.

7.  IN CONCLUSION

  7.1  The NHS can enhance its impact by commissioning organisations such as NGOs and universities to undertake health inequalities work, where they have specialised expertise, and exercise its leadership role in strategic partnerships, especially with local authorities.

  7.2  Success will not be achieved without a much greater investment in local public health capacity, including health promotion and community development.

  7.3  NHS organisations should use their economic power to influence supply chains.

  7.4  The NHS should use its capital funding and role as a major employer to invest for the greatest community health gain, taking the longer term view into account.

  7.5  Services should be planned to meet the needs of communities rather than expecting disadvantaged groups to meet the needs and constraints of the NHS.

  7.6  The NHS should provide specialised technical advice on issues such "health impact assessment", "equity audit", "needs assessment", and "community development" to other public bodies.

  7.7  In the longer term interests of health, NHS bodies should be a model of good practice when it comes to sustainable development.

  7.8  The RSH, RIPH and the NGO Forum would welcome an opportunity to discuss these issues with the Health Select Committee and are happy to assist the Committee with its investigations.

January 2008

  1.  Action for Blind People

  2.  African HIV Policy Network

  3.  Age Concern England

  4.  ASH (Action on Smoking and Health)

  5.  Association for the Study of Obesity

  6.  Association of Directors of Public Health

  7.  Association of Directors of Social Services

  8.  Asthma UK

  9.  Barnardo's

  10.  Black Health Agency

  11.  British Dental Association

  12.  British Dental Health Foundation

  13.  British Dietetic Association

  14.  British Flouridation Society

  15.  British Heart Foundation

  16.  British Medical Association

  17.  British Nutrition Foundation

  18.  Brook Centres

  19.  Cancer UK

  20.  Child Poverty Action Group

  21.  CIEH—Chartered Institute of Environmental Health

  22.  Clubs for Young People

  23.  Commission for Racial Equality

  24.  Community Action Network

  25.  Community Development Exchange

  26.  Community Health Involvement & Empowerment Forum

  27.  Consensus Action on Salt and Health (CASH)

  28.  Consumers Association

  29.  Continyou

  30.  Council of Ethnic Minority Voluntary Sector Organisations (CEMVO)

  31.  CSV

  32.  Diabetes UK

  33.  Drug Scope

  34.  Equalities National Council

  35.  Faculty of Public Health

  36.  Faithworks

  37.  Food Commission

  38.  Forum for the Future

  39.  FPA

  40.  Homeless Link

  41.  Institute of Rural Health

  42.  JCWI—Joint Council for Welfare of Immigrants

  43.  Lesbian & Gay Foundation

  44.  Local Government Association

  45.  Medical Foundation for AIDS & Sexual Health

  46.  Meningitis Trust

  47.  Men's Health Forum

  48.  Mental Health Providers Forum

  49.  MIND

  50.  Muslim Council of Great Britain

  51.  National Aids Trust

  52.  National Children's Bureau

  53.  National Healthy Living Alliance

  54.  National Heart Forum

  55.  National Council of One Parent Families

  56.  NEA (National Energy Action)

  57.  No Smoking Day

  58.  NSPCC—National Society for Prevention of Cruelty to Children

  59.  Nuffield Trust

  60.  Nutrition Society

  61.  Patient information Forum (PiF)

  62.  Patients' Association

  63.  Pharmacy HealthLInk

  64.  Royal College of General Practitioners

  65.  Royal College of Midwives

  66.  Royal College of Nursing

  67.  Royal College Physicians

  68.  Refugee Council

  69.  RNID

  70.  RoSPA—Royal Society for the Prevention of Accidents

  71.  RPSGB—Royal Pharmaceutical Society of Great Britain

  72.  SANDS (Stillbirth and Neonatal Death Society)

  73.  Scarman Trust

  74.  Save the Children Fund UK

  75.  Society for Health Education & Promotion Specialists

  76.  Society of Local Authority Chief Executives and Senior Managers

  77.  South Asian Health Foundation

  78.  Stroke Association

  79.  Students in Mind

  80.  SUSTAIN (alliance for better food & farming)

  81.  Sustrans

  82.  The Kids' Cookery School

  83.  Terence Higgins Trust

  84.  The Obesity Awareness & Solutions Trust (TOAST)

  85.  Trading Standards Institute

  86.  UKPHA

  87.  UNITE

  88.  World Cancer Research Fund

  89.  Womens' Institute

  90.  YMCA England