1.  EXECUTIVE SUMMARY

  1.1  This response focuses on the three major risk factors for chronic disease—tobacco use, poor diet and lack of physical activity. There are significant inequalities between socioeconomic groups in the UK both in terms of disease prevalence (CVD, type 2 diabetes, many cancers and chronic lung disease) and the behaviours that lead to the diseases. Preventing chronic disease, therefore, requires tackling any inequalities that discourage healthy decision-making.

  1.2  This response focuses on the drivers of chronic disease and how healthy lifestyles can be encouraged, including by the NHS.

2.  THE OXHA APPROACH TO HEALTH INEQUALITIES[207]

  2.1  The Oxford Health Alliance (OxHA) is a global charity registered in England and Wales that works to reduce the global epidemic of chronic disease (CVD, type 2 diabetes, many cancers and chronic lung disease) through tackling three major risk factors—tobacco use, poor diet and lack of physical activity. There are significant inequalities between socioeconomic groups in the UK both in terms of the disease prevalence and the behaviours that lead to the diseases (see appendix 1). Preventing chronic disease, therefore, requires tackling any inequalities that discourage healthy decision-making. For example, of particular concern to OxHA—given its focus on the three risk factors—are:

  2.2  Tobacco use:

—  In 2004, the Health Survey for England 2005: The Health of Minority Ethnic Groups shows that 40% of Bangladeshi men, 29% of Pakistani men and 20% of Indian men smoke[208] compared with a national average for the whole population of 24% of adult men.

—  According to ASH (Action against Smoking and Health), smoking is the major cause of health inequalities in the UK accounting for two-thirds of the difference in risk of premature death between social classes.

—  Death rates from tobacco are two to three times higher among disadvantaged social groups than among the better off (ASH).

—  Long-term smokers are disproportionately drawn from lower socio-economic groups. People in poorer social groups who smoke, start smoking at an earlier age: of those in managerial and professional households, 31% started smoking before they were 16, compared with 44% of those in routine and manual households (ASH).

  2.3  Poor diet:

—  According to the Health Survey for England 2002, 10% of girls in households where the reference person worked in routine or semi-routine occupations eat the recommended number of portions compared to 14% in managerial/professional households. For boys the respective figures were 9% and 14%.

—  According to the Food Standards Agency Low Income Diet and Nutrition Survey, men and women with a lower level of educational achievement tended to have a "less healthy" diet, eating fewer vegetables and more chips, fried and roast potatoes.

  2.4  Physical activity:

—  88% of men in the highest income quartile took part in some form of physical activity each month (on an average of 13.5 days); this drops to 66% on an average of 10.2 days each month for those in the lowest income quartile[209]

  2.5  Obesity:

—  61.5% of women with routine/manual jobs have a BMI of over 25; this is significantly higher than the 49.8% among those in managerial/professional occupations[210]

3.  COMMENTS ON THE DRIVERS OF HEALTH INEQUALITIES

  3.1  OxHA believes that chronic disease prevention is dependent on keeping people healthy (ie encouraging lifestyle change) rather than treating those who are ill; therefore, along with the role the NHS plays, there are many drivers that are (as noted in the Terms of Reference of this Select Committee Inquiry) outside its remit. In fact, the NHS is only one of many stakeholders responsible for ensuring that the healthy choices become the easy choices, and it must work side-by-side with other partners in order to achieve this aim.

  3.2  For example, a good diet requires that healthy, fresh foods (not high in fat, sugar and salt) should be:

—  accessible—those on low incomes may not live near supermarkets or other shops that sell fresh fruit and vegetables—and if local areas are perceived as unsafe, or if public transport is insufficient, it may be difficult to access the foods in supermarkets

—  available—local corner shops may simply not stock good-quality fresh foods

—  appropriate—foods locally may not be culturally appropriate for those from ethnic minorities

—  affordable—the healthy options may not be the cheapest options—particularly for those on low incomes, the relative low cost of calories from HFSS foods means that they are the most likely to be purchased.

  3.3  Although the NHS does not play much of a role in the above, it does play a role in making individuals aware of the impact of a poor diet on their health as well as helping them understand how they can go about changing their behaviour. For example, health professionals must be confident in talking to their patients about their weight and possible risk of disease if they do nothing to improve their lifestyles.

  3.4  There is, indeed, a danger that spending money on public health interventions that rely solely on education (eg social marketing campaigns) rather than structural changes could increase inequalities, as raising awareness among the least-well off may not be sufficient, so only those on higher incomes will be able to make the lifestyle changes. Similarly, raising taxes on tobacco products may discourage smoking—but among those who are not able to give up the habit, it will take up a higher proportion of the income of those on low earnings.

  3.5  For change to reach all incomes, a raft of measures would be needed: ensuring a good land-use mix (eg planning for local shops near residential areas), encouraging farmers' markets and other ways of distributing healthy foods locally, providing good public transport links where there are no local shops, and making the streets safe for travelling.

  3.6  Similarly, opportunities for physical activity require:

—  safe streets—walking and cycling are two of the most popular forms of exercise, but many people (particularly those with children) do not regard the streets as safe enough to use

—  access to green spaces—preferably on foot, or with good public transport access

—  affordable leisure/sport opportunities—for example, local swimming pools and recreation grounds, that are cheap and safe for children and adults alike

—  opportunities for physical activity at work (where jobs are sedentary) and at school.

  3.7  The NICE Guidelines on obesity touch on many of these issues, and provide a model for other countries as well as the UK, as they take a whole-systems approach to tackling the problem—looking at the role of the NHS but also of employers, the education system, urban planners and others. As the Terms of Reference state, many of these issues are beyond the reach of the NHS, but this is no reason for the NHS not to get involved.

4.  SUGGESTIONS FOR THE ROLE OF THE NHS

  4.1  While the role of the NHS in facilitating healthy lifestyles may be limited, there are, of course, things that can be done.

—  Set a good example! The NHS is the country's largest employer, employing more than 1.3 million people, so it is well placed to lead by example. In addition, if nurses, doctors and others have made changes to their own lifestyles, they will be better able to advise—and talking to people about the importance of changing lifestyles is a strong driver for change, especially when 80% of all GP visits are chronic disease-related.

—  Any public-health campaigns should pay particular attention to the needs of the less advantaged and ethnic minorities, in order in order to avoid widening relative inequalities in smoking and smoking- or diet-related health outcomes.

5.  WHAT WORKS?

  5.1  The Oxford Health Alliance is currently piloting a new initiative, Community Interventions for Health, which will measure the impact of a series of interventions (in workplaces, schools, local communities and healthcare centres) across sites in four countries—in cities in China, India, Mexico and England.

  5.2  The CIH programme will have the following components:

—  Community coalition-building—key stakeholders will work together to encourage healthy lifestyle change throughout the community, such as advocating for bicycle paths and smoke-free environments or creating farmers' markets

—  Health education—dissemination of health messages, such as the training of health professionals, using mass media, social marketing or peer educators.

—  Structural change—structural interventions such as advocating for and implementing policy change, environmental change (improving opportunities for physical activity in schools and workplaces) and economic change (reducing taxes on healthy foods). These components interact to create communities in which the healthy choices are the easy choices.

  5.3  With regards to healthcare settings, the following (proven successful) structural interventions, among others, will be put in place:

—  provide healthy meals in canteens and vending machines;

—  revise health assessments to include diet and physical activity questionnaires;

—  provide better training for healthcare professionals to advise patients on healthy diet;

—  create places for access to physical activity;

—  promote walking/ bicycling to healthcare settings instead of using cars;

—  train healthcare professionals to prescribe exercise.

  5.4  Each site programme will reach 5,000 people directly and—it is hoped—many more indirectly, and the interventions will be evaluated. These interventions will focus on tobacco control, and encouraging healthier diets and more physical activity. The intervention site in England (Leicester) is a relatively deprived area, and we hope that the interventions will have a significant impact upon the socio-economically disadvantaged.

January 2008

  Source: Health Survey for England, 1998 and 2001.

208   http://www.ic.nhs.uk/webfiles/publications/healthsurvey2004ethnicfull/HealthSurveyforEngland210406_PDF.pdf Back

209   http://www.ic.nhs.uk/webfiles/publications/opan06/obesity%2C%20physical%20activity%20and%20diet%20tables.xls table 4.3 Back

210   http://www.ic.nhs.uk/webfiles/publications/opan06/obesity%2C%20physical%20activity%20and%20diet%20tables.xls table 2.3 Back