1.  INTRODUCTION

  1.1  The National Heart Forum (NHF) is the leading alliance of over 50 national organisations working to reduce the risk of chronic disease in the UK. Member organisations represent the medical and health services, professional bodies, consumer groups and voluntary organisations. This submission does not necessarily represent the views of all of our member organisations.

  1.2  Ten years after the publication of the Acheson Report[309], health inequalities still represent a significant if not greater challenge. Among men life expectancy at age 65 is currently 4 years higher for those in social class I than social class V, while the gap among women has widened significantly over the past 20years[310]. These differences are even more pronounced when geographical variations are taken into account. Although mortality rates for cardiovascular disease have been decreasing at both ends of the social scale, they have been decreasing much more quickly among upper socio-economic groups and this difference has made a large contribution to the widening of inequalities in mortality. Improved standards of living and health care have improved everyone's chances of living longer but the least well off have gained least[311]. This will be reiterated in a forthcoming publication on inequalities in cardiovascular disease to be published by the BHF Health Promotion Research Group at University of Oxford[312].

  1.3  The NHF believes that the need to tackle health inequalities should be an intrinsic part of any public health strategy. Unfortunately public health has borne the brunt of many of the changes and financial crisis within the NHS in recent years. In order to meet the challenge of tackling health inequalities, the NHF makes the following recommendations

  1.4  The Government should invest in an independent, credible and authoritative public health system to help fully engage the public, positively alter the health culture and encourage healthy lifestyles in England.

  1.5  The Government should establish a National Institute for Public Health in England focusing on non-communicable diseases to complement the work of the Health Protection Agency. It should be accountable to the CMO for England and work across Government.

  1.6  The Government should introduce a new Public Health Act to provide the legal powers and duties of the state to create the conditions to enable the people to be healthy-to identify, prevent and ameliorate risks to health in the population. It should also challenge the current limitation to the power of the state to constrain the autonomy, privacy, liberty, property or other legally protected interests of individuals for the protection or promotion of community health[313]. These duties should include the requirement to carry out an independent health impact assessment on all policies in a similar manner to the current requirement to carry out a Regulatory Impact Assessment.

  1.7  The NHF believes that there is an increasing need for the government to address these commercial determinants of health if it is to avoid seeing a further increase in health inequalities.

  1.8  The NHF also supports the comments and recommendations on Tobacco control made by ASH and the Faculty of Public Health in their submissions to the Health Select Committee enquiry.

2.  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;

  2.1  The NHF believes that the NHS can clearly contribute to reducing health inequalities. Examples include undertaking screening as announced recently by the Prime Minister[314] (however if this is carried out on a voluntary basis it may exacerbate inequalities) or as a facilitator in joining up working across public health and local government agendas and in managing joint working toward inequalities targets. However the NHF is concerned that a continuing emphasis on area-based interventions characterized by the current Spearhead initiatives is a consequence of political rather than evidence-based necessity and will fail to reach the majority of those in need of help. The current emphasis on Spearhead areas will inevitably—as with all area-based initiatives—fail to reach the majority of those in the lowest socio economic groups.

  2.2  The potential role of the NHS to tackle health inequalities is clearly impaired by the impact that "wider determinants" such as taxation, employment, housing, education and local government play on health as characterised in the Department of Health's own Health Inequalities Programme for Action[315]. Recent Public Health policy has been characterized by the notion of health as a matter of choice[316], in some respects as a limited interpretation of Wanless's "Fully engaged scenario" set out in his two reports for HM Treasury[317], which as well as highlighting individual responsibility, also noted that corporations shape social norms as well as meet consumer demand. He argued that the private sector must move towards "full engagement" in public health (as well as the public and voluntary sectors) if the spiralling costs attributable to avoidable chronic disease are to be checked. This individual approach espoused in Choosing Health is in stark contrast to previous policy which focused more on improving material circumstances in order to improve health.

  2.3  Whilst individuals clearly have a role to play in determining their own health, the NHF supports the notion championed in the recent Foresight report, Tackling Obesities[318] which challenges the assumption that our health is predominantly a matter of our own choice and responsibility. In relation to obesity, it concludes that the evidence supports the concept of "passive obesity" (where obesity is encouraged by wider environmental conditions, irrespective of volition). Today, the majority of people in the UK are sedentary when at work and at home. Eating habits have become more unstructured, and low-cost, energy-dense "foods high in fat, sugar, salt and drink on the go" are widely consumed. For a multitude of reasons, healthy lifestyles may be less available to those on low incomes who are poor in terms of both time and money. Therefore, people do not "choose" to be obese. Their obesity is driven by a range of factors that constrain individual choice and are beyond their immediate control.

  2.4  The NHF believes that in order to fully understand health inequalities we need to examine the broad environment including social, economic and cultural circumstances. There is a predominant culture in our society which is highly unequal, competitive, materialistic and individualistic. Evidence increasingly suggests that what might be termed the "commercial determinants of health" are having a prevailing negative impact on many of the risk factors which create health inequalities.

  It should be noted that commercial organisations and their products do have the potential to have significant, positive public health effects. The creation of wealth and employment enables better standards of living and generally promotes health when employment policies and business practices are fairly and appropriately regulated. However, the extrinsic costs which arise from negative health impacts of business practices are borne by society, not industry and generally by those at the lower end of the social scale.

  2.5  However, changes in the national diet towards energy-dense convenience foods, drinks and snacks are partly responsible for major public health epidemics of obesity, type 2 diabetes and hypertension. The food industry by its nature is continually battling to increase demand and sales and despite innovating products high in fat, sugar or salt and marketing them relentlessly to all ages, the industry is not subject to any controls or sanctions in the interest of public health, either as a precautionary principle or in line with a principle that the "polluter must pay".

  2.6  An illustration of how commercial interest can potentially exacerbate inequalities is the current duality of food labeling schemes currently adopted by both retailers and manufacturers.

  2.7  A large scale quantitative study commissioned by the Food Standards Agency demonstrated firstly that all four signposting methods including a multiple traffic light (MTL) and Guideline Daily Amounts (GDA) not surprisingly, performed better than no signposting in helping consumers make health eating choices.

  2.8  Secondly and significantly in relation to the health inequalities debate in individual product assessments, MTL performed best across all socio-economic groups including C2 (89% correct responses compared with 67% with GDA) and DE subgroups (89% compared with 65% with GDA). Among the main minority ethnic groups, MTL performed best in the individual product evaluation (93% correct responses against 66% for GDA)[319]. Despite, government support for the MTL scheme and consumer demand for a single scheme in the market, two of the four major supermarkets and most of the leading manufacturers have chosen to adopt the GDA scheme. The failure of these companies to fall in line with the government-preferred MTL scheme—which demonstrably works better with consumers in lower social groups—risks not only confusion for consumers, but widening dietary inequalities.

  2.9  Given the current plateau in smoking rates coupled with increasing burdens of diet and alcohol related illness which are all greater for those in lower socio economic groups, there is an increasing need for the government to address these commercial determinants of health if it is to avoid seeing a further increase in health inequalities.

  2.10  The NHF recommends that the government gives greater consideration to the commercial determinants of health particularly with respect to their impact on health inequalities.

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  As previously noted evidence clearly demonstrates that the key lifestyle determinants of future health, smoking, diet and alcohol, all have a greater impact on those in lower socio economic groups. Smoking rates are higher amongst the lower socio economic groups who also show the greatest resistance to smoking cessation interventions. It has been suggested that much of the rise in life expectancy we have seen in recent years can be attributed to the fall in rates of smoking.[320] According to the Office for National Statistics, the overall smoking rate bottomed out at its present level in 2001 and has remained stable ever since.

  3.2  Obesity and its attendant illnesses are rising rapidly across all socio-economic groups. They are rising fastest amongst the lower classes as the less healthy energy dense foods high in fats, sugar and salts also tend to be the cheapest and the most heavily marketed. Similarly there are significant inequalities in physical activity rates in part as a consequence of the environment which those in low income are likely to live in. This would perhaps support a suggestion that we should reduce inequalities by targeting key causes such as smoking and obesity.

  3.3  Whilst NHF support this type of approach, it also supports the comments and recommendations made by ASH and the Faculty of Public Health in their submissions to the Health Select Committee with respect to tobacco control.

  3.4  However international examples demonstrate that it is not always the richest countries, rather the most egalitarian that have the best health, as our understanding of the impact of relative deprivation on our health increases. So perhaps in the longer term, the biggest impact on health inequalities will come from reducing social inequalities, this is outside the scope of public health services but within the remit of other Government departments, particularly the Treasury.

  3.5  In addition NHF believes that The Government should invest in independent, credible and authoritative public health system to help fully engage the public, positively alter our health culture and encourage healthy lifestyles in England.

  3.6  In order to achieve this, the Government needs to establish a National Institute for Public Health for England focusing on non communicable diseases to complement the work of the Health Protection Agency and be accountable to the CMO for England and work across Government.

  3.7  In order to support these new structures the government needs to introduce a new public health act to provide the legal powers and duties of the state to assure the conditions for the people to be healthy-to identify, prevent and ameliorate risks to health in the population- and the limitation on the power of the state to constrain the autonomy, privacy, liberty, property or other legally protected interests of individuals for the protection or promotion of community health[321].These should include the need to carry out a health impact assessment on all policies in a similar manner as currently exists in the requirement to carry out a Regulatory Impact Assessment.

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  One of the difficulties with area based interventions is that although it is possible to develop indices of deprivation for geographical areas it is unusual for the residents to be exclusively deprived, particularly given the gentrification of many traditional inner city deprived areas. There is some evidence that area based initiatives such as Sure Start and Health Action Zones are subject to the same inverse care law which affects other public services. In other words despite there best efforts to target those most in need they often support those with lesser needs.

  4.2  It is difficult to determine whether interventions such as Health Action Zones were effective particularly as they were not given sufficient time to meet their aims before being disbanded. Whilst in many cases the projects may not have shown significant short term gains it is also true that many which have had initially promising results have been shown not to be sustainable beyond the short term.

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.

  5.1  The Department of Health "Health Inequalities Programme for Action[322]" clearly sets out those actions most likely to have the greatest impact in tackling inequalities in health. The role of the Director of Public Health in each PCT is crucial in joining up initiatives to tackle health inequalities.. However, increasingly in recent years they have been inadequately resourced to carry out this role. When NHS budgets are cut, it is always public health that, is disproportionately affected in order to minimise cuts to acute healthcare services. This is a short-sighted policy that works against the capacity of the NHS being able to reduce health inequalities, because of the longer timeframes involved.

  5.2  Recent reforms of public health have resulted in a substantial loss of workforce capacity, with many of the most experienced and well-respected public health staff leaving the profession or at least leaving the NHS. Public health delivery requires continuity not reorganisation, so that workforce capacity at all levels can be built up. Stability is required not only for recruitment and retention but to enable local knowledge, relationships and trust to be built up to enable efficient and effective joint working across different types of organisations and providers.

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 Department of Health has developed significant resources and expertise in tackling health inequalities in recent years. The NHF welcomed the establishment of a Health Inequalities Unit within the Department.

  However, coordinating policy across government departments has always proved difficult, other government departments are driven by their own PSA targets. This is the by product of a target-driven policy agenda.Until all departments are aware of and act upon their ability to influence these determinants of health, the Department of Health will continue to be regarded as the Department of the NHS—a curative rather than a National Disease service.

  6.2  Virtually all Government programmes have the potential to narrow health inequalities or, indeed, to widen them. Therefore to be truly effective, it is essential that the DH works together in co-delivery mode with local government. The Government is encouraging and supporting local authorities to improve the health of their communities and to tackle health inequalities. Local authorities working in effective partnership with the NHS, other public sector bodies and the private, voluntary and community sectors is crucial to tackling the health problems in their areas.

7.  WHETHER THE GOVERNMENT IS LIKELY TO MEET ITS PUBLIC SERVICE AGREEMENT TARGETS IN RESPECT OF HEALTH INEQUALITIES.

  7.1  While the Government persists with an individual-focus to health and inequalities, there will be difficulties in meeting targets. Perhaps we should be focused on sticking to targets which have been subject to a number of alterations in their spatial and social units and timings. Neither, the target for local authorities or that for infant mortality set out below are true health inequalities targets because they compare the worst off groups with the average of the population as a whole rather than considering the entire distribution.

—  Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between routine and manual groups and the population as a whole.

—  Starting with local authorities, by 2010 to reduce by at least 10 per cent the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators (the Spearhead Group) and the population as a whole.[323]

January 2008

310   Donkin et al (2002) ONS Longnitudinal Study 1977-1999, England and Wales. Back

311   Mackenbach JP et al (2003) Widening socioeconomic inequalities in mortality in six Western European Countries in International Journal of Epidemiology 32, pp 830-837. Back

312   BHF Health Promotion Research Group at University of Oxford Regional and Social Differences in Coronary Heart Disease Forthcoming. Back

313   Gostin L (2004) Health of the People the Highest Law. Conference proceedings, Nuffield Trust, London. Back

314   Prime Minister statement reported on BBC website http://news.bbc.co.uk/1/hi/uk_politics/7174340.stm 07.0108. Back

315   Department of Health (2003) Tackling health inequalities: A Programme for Action London: DH. Back

316   Department of Health(2004) Choosing health: Making Healthier choices easier London: DH. Back

317   Wanless D (2002) Securing our future health & (2004) Securing good health for the whole population both London: HM Treasury. Back

318   Foresight tackling Obesities : Future Choices (2007) London: GOS. Back

319   http://www.food.gov.uk/foodlabelling/signposting/siognpostlabelresearch/ accessed 19th December 2007. Back

320   Dr John Powles (Cambridge University) speaking at joint NHF/LSE/ RCP seminar 27th Feb 2006. Back

321   Gostin L (2004) Health of the People the Highest Law. Conference proceedings, Nuffield Trust, London. Back

322   http://www.dh.gov.uk/en/Publichealth/Healthinequalities/ProgrammeforAction/index.htm Back

323   http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Healthinequalities/Healthinequalitiesguidancepublications/DH_064183 Back