Middletonjb

Public health white

paper 2010

The ‘life-course’ approach

• Early years

• Start well

• Working well

• Living well

• Ageing Well

• Reducing social inequalities: UK Marmot review

• Early years education and family support: increase % spend in early years

• Maximise the capabilities and control young people have over their lives : reduce the social gradient of skills

and qualifications

• Create fair employment and good quality work for all and improve quality of work across social gradients

• Ensure healthy standard of living for all reducing the social gradient through progressive taxation and other

fiscal policies

• Healthy and sustainable physical environments

• Strengthen the role and effect of prevention of ill health priority for investment to reduce social

gradients

• Reducing social inequalities:

UK Marmot review

• Early years education and family support: increase

% spend in early years

“Changing the world – one baby at a time”

6

Trials of the NFP

in USA

• Low-income

whites

• Semi-rural

• Low-income

blacks

• Urban

• Large portion

of Hispanics

• Nurse versus

paraprofessio

nal visitors

Elmira, NY

1977

N = 400

Memphis, TN

1987

N = 1,138

Denver, CO

1994

N = 735

7

Consistent results

across 3 trials in USA

• Improvements in women’s antenatal health

• Reductions in children’s injuries

• Fewer subsequent pregnancies

• Greater intervals between births

• Increases in fathers’ involvement

• Increases in employment

• Reductions in welfare dependency

• Reduced substance use initiation and later problems

• Improvements in school readiness

Program effects greatest among

those most susceptible

Evidence for early years support

Perry Preschool High Scope study

Abercedarian university study

Cochrane review of early years and family

support for deprived communities

6 sound studies review of Harden, Oakley et

al BMJ 2009

0 10 20 30 40 50 60 70

Did homework at age 15

In program for mental impairment

IQ at 5 90 or more

9th %ile or better in school at 14

Average or better literacy at 19

Data from the High/Scope Perry preschool project. Bars represent percentage in each of the

two groups. The difference in major educational performance findings between program and

non-program children is significant.

Program No program

0 20 40 60 80

5 or more arrests by age 27

Soc.Services ever in previous 10 years

High school graduate

Home owner at age 27

$2000 or more monthly pay

Further data from the High/Scope Perry preschool project. Benefits from the program

continue to be seen in adulthood. Bars represent percentages of each of the groups The

difference between program and non-program children is significant.

Program No program

•Reducing social

inequalities: UK Marmot

review

• Maximise the capabilities and control young and

adults

people have over their lives : reduce

the social gradient of

• Reducing social inequalities: UK

Marmot review

• Create fair employment and good quality work for all

and improve quality of work across social gradients


UK Marmot review

• Ensure healthy standard of living for all

reducing the social gradient through progressive

taxation and other fiscal policies


UK Marmot review

The spirit level -

Richard Wilkinson work looking at how the

more equal societies are invarialy

healthier, happier, more free of crime,

better achievers with lower unintended

pregnancy rates and other adverse social

indicators


UK Marmot review

• Healthy and sustainable physical environments-

Supportive environments - safe routes to school

Increasing the supply

of healthier food in

Sandwell

From this….

….to this

By 2003 the mixed use site was in production…

Increasing

the

production

of

healthier

food _

Sandwell

community

agricultur

e strategy

Making it Happen

Editorial

“The challenge is to make

politicians work for an environment that promotes walking, and to call on doctors to encourage patients to

walk…”

BMJ 9th June 2007

Healthy towns-Sandwell

Healthy Urban Development

Unit Outcomes

• Healthy urban development approach

• Working with town planners and transport engineers – to influence policy and design

• Emphasis on environment and open spaces- create safer places where people

• Encouraged to walking and cycling

• Health impact assessment on all developments

• Spin off for comments on health care impacts eg new nursing homes

Reducing social

inequalities: UK Marmot

review

• Strengthen the role and effect of

prevention of ill health priority

for investment to reduce social

gradients-

will discuss in relation to NICE

guides

Reducing the social gradient

through targetted health

promotion

• Cardiovascular disease

identifying people at risk

Implementing effective interventions : NICE public health guidelines

Cardiovascular disease identifying people at risk

Communities for health Sandwell model

• Nurse led programme of CVD risk management for patients at> 20% risk

of heart attack in 10 years

• Health trainer intervention for those >15% risk

• Universal advice and information service via community organisations

for general population at lesser risk

Sandwell CVD risk reduction model:

projected benefit

Sandwell Eligible

for

treatment

CVD Events

prevented over ten

years

Aspirin 11,382 410

Antihypertensive

therapy

6,860 288

Statin 11,694 947

Total 1,645

Total if attendance

same as for pilot

1,020

If 30% of

circulatory events

result in death,

then lives saved

494 based on

eligibility

306 based on

eligibility and

Martin Bobak about the catastrophic rise in death rate in Russia in 1990-1995 due to destruction of

Soviet economy

Will western countries under austerity measures be spared extra

deaths?

Stuckler and McKee argue that social welfare spend should be preserved in times of recession and reduced in

good times.

WHO have argued health investment is protective for national economies

(Brundtland 2000,susana 2010)

Public health – a role

for councils

The Changing landscape for public health in England, John Middleton Warrington, March 2nd 2011

Civic Pride

That the people I represent die younger than people in other parts of the country is

not acceptable –

That the people in one part of my area are dying younger than others is unacceptable


Sun cream, health fairs and pest control ?

Or :

Housing and excess winter deaths,

Air quality and heart disease,

Traffic congestion and walking to school

Fear of crime and lack of exercise ?

Littering and obesity ?

The Changing landscape for public health in England, John Middleton Warrington, March 2nd

2011

The inverse care law:

‘People who need the most health care get the worst, and the poorest quality’

‘Poor people get poor services’


Thank you

John Middleton

Director of Public Health for

Sandwell

John.middleton@sandwell-

pct.nhs.uk

Vice President, UK Faculty of

Public Health

[email protected]

mailto:[email protected]



Health & Medicine

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