The roots of poor health in England

According to a National Audit Office review published this summer, the Department of Health estimates that only “15-20 per cent of inequalities in mortality rates can be directly influenced by health interventions, which prevent or reduce the risk of ill health”.

Blackburn with Darwen - with the fifth worst male life expectancy and tenth worst female life expectancy in England - used the Marmot Review framework and an integrated strategic needs assessment approach to analyse the “causes of the causes” of the borough’s poor health outcomes and came to similar conclusions.

In identifying the causal chains leading to low life expectancy, analysis found that “high levels of deprivation across the borough are generating poor social, economic and environmental conditions in specific ‘at risk’ communities. This, in turn, is leading to poor health behaviours and poor health outcomes”.

Blackburn with Darwen is the 17th most deprived council in England and came second in last year’s Ipsos Mori Area Challenge Index. With 37 per cent of residents having no educational qualifications, 46 per cent of properties judged “non-decent”, 12.9 per cent of households in fuel poverty, 35 per cent of adults of working age out of paid employment and, consequently, one in four children living in a workless household, it is not surprising that 24 per cent of citizens are drinking alcohol to hazardous or harmful levels.

The borough has agreed a health inequalities recovery plan with the Health Inequalities National Support team but, as the NAO report implies, without addressing the wider social and economic determinants, the NHS will still be investing the same resources for the same reasons in 100 years time.

Inequalities in education, housing, employment, transport, income, criminal justice and health are all driven by the same root causes and experienced by the same communities. They cannot be solved by single sector responses. As the NAO argues: “Just providing better or more public services will not provide a sustainable solution to the challenges - only a transformational approach can make a difference”.

The transformational reframing recommended in the report involves a shift from “health” to “life chances” and from “NHS spend” to “total public sector spend”. It then becomes clear that any effective response will require a “public health informed” approach to all public sector planning, investment, management, engagement and governance and, as the Marmot report implies, a generational perspective. It will also require vision, leadership and the investment of political capital because only a single and integrated public sector offer with a “one plan approach” could ever be transformational enough to work.

History lessons

Blackburn with Darwen is making great progress. It has a local public sector board to take forward shared priorities for action and has set up a single management structure between the council and care trust plus, saving £2m for frontline services. This will increase capacity to drive further strategic integration and develop future transformational interventions.

During the early 1800s, the towns of Blackburn and Darwen were global innovators in cotton spinning and weaving, but rapid urbanisation brought public health problems that threatened economic viability. Between 1811 and 1852, regular epidemics of scarlet fever, typhus, smallpox and cholera began testing the confidence of investors. The 1851 incorporation of the town council, with confident civic leadership driven by clear public health advice, forged transformational interventions to improve health and create an environment supportive of wealth production.

Over the next 50 years the council brokered the “fixing” of everything that would make a difference - taking over and, (mostly) later handing back a range of social, economic and environmental infrastructures.

Similar opportunities are present today. There are 10,000 local citizens on employment and support allowance, costing some £80m; better health would vastly improve labour market productivity, economic capacity and wellbeing. With alcohol among the biggest single drivers of preventable disease, local government intervention could both improve health and reduce preventable NHS expenditure.

If the new local government public health function is to improve population health outcomes, its focus will need to be on improving population life chances as a whole, with 80 per cent of its work directed outside of NHS service delivery domains. It will need to drive transformational and systemic change at the level of whole public sector investment. To deliver this, directors of public health will need significant positional authority and a continued guarantee of robust independence in their new role.

Dominic Harrison is director of public health for NHS Blackburn with Darwen Teaching Care Trust Plus.