I recently had the privilege of attending a lecture by Sir Michael Marmot, the guru of health inequalities and public health.
Sir Michael described evidence that much of the ill health in the North East is related to socio-economic inequality. He highlighted a north-south divide in health inequalities but also noted that in parts of our region some people live, on average, eight years less than more prosperous areas. The gap in disability-free life expectancy is even higher.
Changing this is truly a daunting challenge.
In the North East we have seen a marked decline in cardiovascular disease premature mortality, reflecting the high levels of investment in secondary care and effective tobacco control programmes. There is still, though, no groundbreaking progress in narrowing the gap in cancer mortality. There is also a poor situation with the Marmot indicators of the social determinants of health – 91 per cent are below the England average (compared with 18 per cent in the South East).
Following that lecture, I chaired a policy seminar sponsored by Durham University and attended by leading figures from the Association of North East Councils and the local NHS. The most striking feature of the whole event was the ambition and commitment of the people in the room to collaborate across political and organisational lines to scale up the collective effort to improve public health.
This enthusiasm was underpinned by an “evidence based optimism” borne out of the achievements to date, including leadership by local authorities on tobacco control, a raft of regional and local NHS initiatives and a strong commitment to partnership working.
Creating strategies and plans is easy, changing behaviour is another ball game. At the heart of all this is the tension between nudging and nannying. Government and policy makers are wary of being seen to be too intrusive or too soft on issues like alcohol and obesity and it is difficult to strike a balance between protecting individual freedoms and encouraging personal responsibility.
Nationally, there has been a commitment to encouraging collaboration between sectors of the economy and government departments to tackle the big public health questions. But it seems to me that with fewer resources available, it is going to become much tougher to change fatalistic attitudes towards public health, particularly in communities with high levels of social deprivation.
Equally it is probably true that government intervention will only be successful if people feel ready to accept and bring pressure to bear on friends and neighbours to make change in communities.
Back in our policy seminar we agreed we had yet to fully get to grips with worklessness and the health of long term incapacity benefit claimants. We also discussed the challenge of local cuts and structural changes.
Innovative ideas were shared about more progressive levying of council tax and moving clocks forward two hours in summer so that the extra daylight could promote physical activity and jobs in tourism and leisure.
We reached the following conclusions:
- Dealing with health inequalities means we need continuing cross organisational and sector leadership and ambition for the long term;
- We need to back this up with more than a warm feeling about doing the right things; they need to be demonstrated to work and then industrialised across the area;
- People do not respond well to being told what to do. Interventions need to be done with people or by people themselves. Problems need to be identified with people in their language and solved with them;
- We should get away from polarities of public good and private bad but ask what is the best way to achieve outcomes;
- We needed to continue to share lessons about failure and success.
Wherever you are reading this, what’s your manifesto?