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Annual Public Health Report 2010/11

Changes and Challenges...

Final version 1.0

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Contents

Introduction 3

Chapter 1: Changes and challenges... 6

Chapter 2: Inequalities 12

Chapter 3: Swimming upstream 21

Chapter 4: Obesity - more than an issue of fatness 40

Chapter 5: General Practice - a platform for more 49

Chapter 6: Putting the patient and community centre stage 68

Chapter 7: The power of information 77

Executive summary & recommendations 84

Appendix 1: Progress on the recommendations from last years

annual public health report 91

Acknowledgements 95

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Introduction

Annual public health reports are expected to provide an independent comment on the state of

health, and on local efforts to improve and protect health. They should also be written with a

critical eye and with the public interest in mind.

This year the report covers a number of high-level issues, rather than going deeply into one

particular issue. We wanted to produce a report that would provoke discussion about the broad

and big picture challenges related to health and illness. In particular, this report responds to the

current context of major structural change and reform to the NHS; a large public deficit; and

forthcoming cuts to a number of health and local government services.

There are big and difficult challenges to overcome if the health of the population is to be

maintained and improved, and if unfair and avoidable inequalities in health are to be reduced.

Meeting these challenges will require a shared and coherent vision of health improvement

amongst a wide range of actors and stakeholders, and one aim of this report is to argue for the

creation of such a shared vision.

This report builds on four of the core attributes of public health:

a whole population perspective - rather than one focused on individual patients and service

users;

a whole health systems perspective which includes hospitals, primary care, community

based care, and other health service elements;

an emphasis on the prevention of illness and disease and the wider determinants of health;

strong foundations in monitoring, research, evaluation and systematic review.

The outline of this report is as follows. The first chapter describes the major changes and

challenges facing both the local population and health system. It covers a number of policy-

related issues that are not specific to Hammersmith and Fulham (H&F) but which are nonetheless

important contextual factors.

The second chapter briefly describes the state of health inequalities in H&F. It is the causes,pattern and degree of health inequality that should guide commissioning decisions and strategies,

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rather than the average or aggregate state of population health. For this reason, chapter three is

based on the Marmot Report on health inequalities in England that was published in 2010. We

look at the recommendations from this report and consider their application to H&F.

The fourth chapter is focused on a specific issue: child obesity. It is a serious but still neglected

health priority, and illustrates the importance of prevention. Having discussed a specific

population health issue, chapter five discusses a specific health systems topic: the General

Practice (GP) landscape of H&F. Health systems analysis is an important sub-discipline of public

health, and as GP practices are a critical foundation stone of the health system, we have provided

some data, analysis and discussion about them in this report.

This is followed by two chapters (6 and 7) designed to showcase elements of local public health

work. First, we describe the important work being done to engage with and empower patients and

local communities. Second, we provide some examples of the work being done to improve our

health information systems a critical requirement for ensuring that we invest in the right services

and for ensuring that those services have the right impact. Going against convention, the report

ends with an executive summary, including key recommendations. Finally, there is an Appendix

which reports on the actions taken in response to last years annual public health report.

A requirement for a shared vision of health improvement is a shared understanding of the health

needs of the population. An adjunct to this report is therefore the Hammersmith and Fulham Joint

Strategic Needs Assessment (JSNA) which provides a repository of data, information and analysis

about the local health profile and local services (see box overleaf). JSNA documents can be found

online atwww.hf-pct.nhs.uk/JSNA.

This is a fairly long report covering a wide range of issues. But still, it has many gaps and cannot

be considered a comprehensive report. We note in the report several areas that need future

attention and we hope these may be reflected in future outputs. These include: mental health; the

performance of hospitals and community services; school health; and health expenditure analysis.

However, I hope this report provides some new information and food for thought; and that it will

support debate and discussion!

Dr. David McCoy

Acting Director of Public Health

http://www.hf-pct.nhs.uk/JSNAhttp://www.hf-pct.nhs.uk/JSNAhttp://www.hf-pct.nhs.uk/JSNAhttp://www.hf-pct.nhs.uk/JSNA

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Box 1: JSNA Documents

2009/10

1. JSNA 200910 Executive summary

2. Demographic profile

3. Long-term condition data

4. Disease registers and co-morbidity

5. Mortality data

6. Hospitals admissions

7. JSNA 2009/10 core data set

2010

1. Childrens JSNA

2. Housing and Health

http://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/1%20Executive%20Summarypdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/2%20Demographic%20Profilepdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/3%20Long%20Term%20Conditionspdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/4%20Disease%20Registers%20and%20Comorbiditypdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/5%20Mortalitypdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/6%20Hospital%20Admissionspdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/7%20JSNA%20Core%20Datasetpdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/7%20JSNA%20Core%20Datasetpdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/6%20Hospital%20Admissionspdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/5%20Mortalitypdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/4%20Disease%20Registers%20and%20Comorbiditypdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/3%20Long%20Term%20Conditionspdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/2%20Demographic%20Profilepdf.ashxhttp://www.hf-pct.nhs.uk/AboutUs/Library/~/media/Files/JSNA/1%20Executive%20Summarypdf.ashx

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Chapter 1: Changes and challenges

This years public health report is published in a context of change and turmoil.

Primary Care Trusts (PCTs) will disappear and there will be a shrinkage of management

structures and systems. Since October 2010, the PCT has been going through a process of

downsizing and merger with Westminster and Kensington and Chelsea. Overall staff

numbers have been reduced by around 70 per cent.

Responsibility and money will be handed over to new GP-led Consortia and a new NHS

Commissioning Board (NHSCB)

The different parts of the NHS will be made more independent and free from public

control. All NHS trusts are expected to become or be part of a foundation trust that will

have more freedom to act as independent entities.

European competition law will apply to the NHS for the first time, shifting the health

system further in the direction of a competitive and market-based system.

For the public health discipline, a new national public health service (Public Health

England) will be created and local public health functions will move from PCTs to local

government. There will also be a new ring-fenced budget for public health.

Local government will be given further additional responsibilities for establishing Health

and Wellbeing Boards and Local Health Watches.

Finally, placing patients at the centre of decision-making and giving them more choice

(including the information to exercise that choice) is given strong and new emphasis.

The hope is that these changes will liberate the NHS from excessive bureaucracy and top-

down management; promote greater clinical leadership; and move the NHS towards

becoming the largest social enterprise sector in the world in which competition and

innovation will flourish, and where the patient / consumer will drive up the standard of care

by exercising choice and voting with their feet.

These are big changes to the NHS.Some have called it the biggest shake-up in decades, and

there are many questioning the risks associated with such profound organisational change at a

time when the NHS faces huge financial constraints.

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Although the government has announced a very small rise in the NHS budget, in real terms

there will be shrinkage of NHS spending. Population growth, ageing and the high rate of

inflation associated with medical developments translate into pressure on budgets and having

to do more with less. In addition, some NHS funds will be ring-fenced to supplement adult

social care budgets. In Hammersmith and Fulham (H&F), deficits within the broader health

care economy have already resulted in cuts to some services and plans.

Costly medical and technological advancements dont just mean that more will have to be

done with less; it could also mean that more will be done for only some. As the ability to

treat illness outstrips the publics capacity to pay, the risk of unequal access to treatment

grows, threatening one of the founding principles of the NHS: to provide an equal service to

all on the basis of clinical need.

The financial challenges of the NHS will also need to be managed in the context of even more

severe reductions to other public budgets and services, including a number of local

government services that have a direct impact on health. Public sector job losses combined

with structural deficiencies in the economy will also mean increasing rates of unemployment

and household poverty, both of which are potent determinants of disease and illness, placing

further strain on the NHS.

Difficult decisions will need to be made about how best to make use of public money to

improve health, but even with all the research and evidence in the world, there is no single

correct answer to how resources should be used to maximise health - there are too many

trade-offs and value judgements involved. For example, what value or price do we place on

fairness, and how do we judge what is fair? How do we balance the emphasis between

protecting health for the future while responding to the immediate health needs of the sick in

the present? And what is the price worth paying for the extension of life compared to

improving the quality of life?

Health systems reforms and policies do not only impact on patients and the public; they also

impact on those working within the health system. Different ways of organising the health

system and different priorities result in income streams and benefits being distributed across

the health system in different ways. Hospital doctors, general practitioners, nurses,

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community pharmacists, midwives, health visitors, managers, community-based health

workers, third sector organisations, management consultants, drug companies and health

insurance companies are all actors within the health system; but they operate in a zero-sum

game of finite resources, and each will have an incentive to compete for as big a share of the

pie as possible. Balancing the competing interests of different stakeholders within the health

system and with the competing needs of society is not straightforward.

There is also a need to consider the different purposes of the NHS. While it is mainly a

mechanism to respond to disease, illness and injury; it is also a number of other things. For

example, it is also a market and industry that generates business and returns on capital. It is

also a social and cultural institution that shapes societys attitudes towards, and experience of,

ageing, illness, death and giving birth. And it can also influence the nature of society by

determining how and to what extent economic and social status influences access to health

and health care.

For these reasons, health systems policy should be a matter of public debate and

understanding, even more so given the economic climate and financial predicament of the

NHS. The governments desire to stimulate a more engaged and active citizenry chimes with

this need, and places a challenge and duty on public health professionals to empower people

with the knowledge, information and capacities to participate in such discussions and debates.

So whats to be said about the proposed changes for the NHS in H&F?

There is a lot to discuss and debate in terms of the proposed changes to the NHS, as well as

the policy, economic and demographic challenges described above. However, we highlight

two key messages from a PH perspective.

Whole systems planning, cooperation and coordination

Inpatient wards, outpatient clinics, GP practices, social care services, third sector

organisations, health visitors, community pharmacies, district nurses and expert patients are

all different, but important components of a single health system. They need to be conjoined

to ensure efficiency and effectiveness, and to allow patients to experience a seamless journey

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through the health system. Health systems have been compared to an orchestra for this reason

- different parts of the health system need to collaborate and cooperate in the same way that

the different instruments of an orchestra need to be conducted to play the same music.

At a time of shrinking budgets and reduced management capacity, anything that moves the

NHS towards a more coordinated and efficient whole systems approach will be a good

thing. For example, the past integration of the Primary Care Trust (PCT) and local

government under a single Chief Executive and the pooling of local government and NHS

funds led to many benefits, including a more integrated commissioning plan for community-

based adult and child services.

Although the PCT is no longer integrated with local government (partly due to the fact that

individual PCTs have had to merge to sustain cost reductions), the efforts of the past will

leave behind a legacy of partnership working across the health and social care divide that can

be built on.

There is also a need to ensure better integration within the NHS, particularly across hospitals,

GP practices and community health. Few things are as important as ensuring that primary and

secondary care services work in tandem to address the health priorities of the population.

Neither component of the health system works well without the other.

Although the White Paper provides no specific lever to join up GP practices, community

health services and hospital services, it leaves room for local creativity and innovation.

Currently, there are proposals to develop a system of integrated care for diabetes and care of

the elderly involving Imperial Hospital, GPs, the community health services provided by

Central London Community Health (CLCH) and the local council a significant development

that could pave the way for more effective and efficient whole systems management.

However, the need for better coordination and strategic planning across the health system, and

the wish to encourage greater choice and competition creates a tension. While a more

commercial and competitive approach to health care delivery offers the opportunity for

entrepreneurialism,dynamism and innovation, it carries the threat of greater fragmentation,

inefficiency (for example through excessive income generation and the costs of market

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coordination and regulation) and the undermining of collaboration and cooperation.

Writing recently in the BMJ, one prominent GP commentator wrote of the tension between

competition and cooperation: If the delivery of health care could once again be made a

cooperative and collaborative endeavour, the benefits in terms of morale, enthusiasm, and

renewed altruism could be enormous. Difficult debates lie ahead concerning the increasing

costs of medical technology, the medicalisation of an ever greater proportion of human

experience, the increasing futility and even cruelty of inappropriate and ineffective treatments

at the end of life, and the optimal balance between curative and preventive health care. None

of these can be solved by competition. Only broad public debate and a politics of consensus

offer real hope for the continuation of a humane, inclusive, and affordable health service1

This quote not only raises the importance of cooperation amongst different service providers

for individual providers; it also highlights its importance from a policy perspective and

suggests that a culture of cooperation can be an important determinant of the ethical culture

and standards of a health service. Clearly, rigid and monolithic health systems contain their

own weaknesses and dangers. The critical point is that the forthcoming period of change and

reorganisation must be accompanied by a constant questioning of whether we have the

culture, instincts and set of incentives to avoid unhealthy competition and non-collaboration

within the health system.

Population-wide assessments of health, need and service provision will also become ever

more important, as well as open debate and discussion about priorities. The emphasis placed

on Joint Strategic Needs Assessments (JSNAs) and the proposed establishment of Health and

Wellbeing Boards offer an opportunity for better integration, cooperation and collaboration

amongst providers and commissioners alike.

Prevention

The second key message is that we have to place a greater emphasis on the prevention of ill

health. Maintaining and improving health in the context of an ageing population, rising

1 Heath I, 2010. The costs of the reverberating bedpan. BMJ 2010; 341:c5541 doi: 10.1136/bmj.c5541

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medical costs, shrinking NHS resources and major local government cuts requires the health

system to improve its ability to prevent illness, disease and injury, and to shift the NHS

towards being more of a nationalhealth service and less of a national sickness service.

The health system needs to get better at preventing illness, disease and injury (primary

prevention); and reducing the severity and impacts of illnesses and diseases (secondary

prevention).According to the White Paper on Public Health (Healthy Lives, Healthy People),

changing adults behaviour could reduce premature death, illness and costs to society,

avoiding a substantial proportion of cancers, vascular dementias, and over 30% of

circulatory diseases: saving the NHS the 2.7 billion cost of alcohol abuse; and saving

society the 13.9 billion a year spent on tackling drug-fuelled crime.

Every contact with a patient should be an opportunity for clinicians to promote health, and

prevent illness. This should mean that hospitals which focus on the treatment of illness should

also be seen as a point of care where preventative services are provided. Health professionals

must also advocate for the social, economic and environmental pre-conditions of good health;

and consider how NHS resources can optimise health through non-NHS actors and non-

clinical interventions.

Historically, the NHS has performed poorly in terms of prevention. According to Healthy

Lives, Healthy People, prevention has not enjoyed parity with NHS treatment and that

public health funds have too often been raided by acute and clinical services . One of the

welcome innovations of the new government is that there will be ring-fenced public health

spending, from within the overall NHS budget, to support some of the prevention agenda

(although it remains to be seen whether or not the size of the ring-fenced budget will be

sufficient).

By placing public health resources in local government there is an opportunity to strengthen

the NHSs role in tackling the upstream and social determinants of ill health. This is an issue

that is discussed in chapter 3, but before that, chapter 2 presents and discusses the health

inequalities challenge.

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Chapter 2: Inequalities

Many health inequalities are normal and expected. Perfect health equality is impossible. For a

start, we are all born with a different genetic disposition to disease and illness; we also know

that some conditions are sex-linked, making perfect gender equality in health an impossibility.

However, a significant amount of existing health inequalities are unfair and avoidable. This is

sometimes referred to as health inequities. Furthermore, inequalities in health have been

growing in spite of explicit policies and plans to reduce them. The current economic and

fiscal situation has every prospect of worsening health inequalities still further.

Clearly, there are moral and ethical reasons to eliminate those causes of health inequality that

are unfair and avoidable. But there are also economic and pragmatic reasons. The cost of

improving health amongst those with poor health would, in many instances, be more cost-

effective than improving the health of those who are already relatively healthy.

Sickness and premature mortality amongst those with poor health is also expensive.

Inequality in illness is estimated to account for productivity losses of 31-33 billion per year,

lost taxes and higher welfare payments in the range of 20-32 billion per year, and additional

NHS healthcare costs in excess of 5.5 billion per year. 2 If no action is taken, the cost of

treating the various illnesses that result from inequalities in the level of obesity alone, is

estimated to rise from 2 billion per year to nearly 5 billion per year in 2025.3

In 2009, a high-profile and extensive study on the avoidable causes of health inequalities and

the prevailing policy response to this issue was published: the Marmot Review on Health

Inequalities.4

We summarise the key findings of this report and examine their relevance in

chapter three, but first, a few facts about health inequality in Hammersmith and Fulham.

2 Frontier Economics (2009) Overall costs of health inequalities. Submission to the Marmot Review.www.ucl.ac.uk/gheg/marmotreview/Documents.

3 McPherson K and Brown M (2009) Social class and obesity - effects on disease and health service treatment costs.

Submission to the Marmot Review. -www.ucl.ac.uk/gheg/marmotreview/Documents

4 Marmot Review. Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England post-2010.

http://www.ucl.ac.uk/gheg/marmotreview/Documentshttp://www.ucl.ac.uk/gheg/marmotreview/Documentshttp://www.ucl.ac.uk/gheg/marmotreview/Documentshttp://www.ucl.ac.uk/gheg/marmotreview/Documents

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Unequal Life Expectancy in Hammersmith and Fulham

Inequalities in health are commonly described in terms of life expectancy variations. For

example, in Hammersmith and Fulham, there is a 7.1 year gap in male life expectancy and a

11.7 year gap in female life expectancy between people living in different wards in the

borough (see below).

Male Life Expectancy at Ward Level: 2003/07(Source: London Health Observatory)

Female Life Expectancy at Ward Level: 2003/07(Source: London Health Observatory)

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Interestingly, the fact that females in Hammersmith and Fulham have a larger gap in life

expectancy across wards than males is not reflected across London, where male life

expectancy ranges from 88 years in a ward in Kensington and Chelsea to 71 years in

Lewisham Central (a gap of 17 years) and female life expectancy ranges from 76 years in a

ward in Newham to 90 years in Knightsbridge (a gap of 14 years).

Although average life expectancy has risen in H&F, the gap between the poorer and richer

segments of the population has grown, increasing from 6.1 years in 2001/05 to 9.1 years in

2004/08 for men, and from 2.3 years in 2001/05 to 4 years in 2004/08 for women. The two

graphs below show the trends in life expectancy for men and women comparing people in the

bottom and top tenth of the socio-economic spectrum.

Trend in Male Life Expectancy in Hammersmith & Fulham (Source: APHO)

Trend in Female Life Expectancy in Hammersmith & Fulham (Source: APHO)

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Premature mortality

Underlying the gap in life expectancy is the fact that some men and women, especially those

from lower socio-economic status groups, die early. It is therefore worth looking at the causes

of premature deaths.

In Hammersmith and Fulham, between 2006 and 2008, there were 643 deaths occurring to

adults below the age of 65 years - 414 men (64%) and 229 (36%) women. This translates into

a premature mortality rate of 231 deaths per 100,000 population per year which is above the

London average. Two of the boroughs six statistical neighbours5

(Tower Hamlets and

Islington) have significantly higher premature mortality rates. If Hammersmith and Fulhamhad the same premature mortality rate as Kensington and Chelsea (which has one of the

lowest rates of premature mortality), there would be approx. 50 fewer premature deaths a year

in actual numbers.

Directly standardised rate per 100,000 of premature mortality from all causes, ages 15-

64, 2006-08 (Source: NCHOD)

5ONS Cluster: Camden, Hammersmith and Fulham, Islington, Kensington and Chelsea, Wandsworth, Westminster andTower Hamlets.

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Within H&F, as one would expect, deprived residents have a significantly higher premature

mortality rate compared to the least deprived residents as shown in the figure below.

Crude rate per 100,000 of premature mortality from all causes by local deprivation

quintiles, ages 15-64, 2006-08 (Source: ONS Mortality Files)

The main causes of premature mortality are: cancers (mainly bowel, lung and breast cancers),

circulatory disease and diseases of the digestive system (mainly liver disease). These three

sets of diseases make up about two thirds of all premature deaths. Both breast and bowel

cancers are now the target of early detection screening programmes; and the risk for all of

these diseases is increased by smoking and unhealthy levels of alcohol consumption.

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Percentage of premature deaths by underlying cause: 2006-08

(Source: ONS Mortality Files)

While the early detection of disease and quick access to medical care can help prolong life

and reduce mortality, social, behavioural and environmental factors that determine

vulnerability and susceptibility to these diseases are what primarily determine the overall

pattern of premature mortality and health inequalities across society.

Dying younger and suffering longer

Differences in life expectancy and premature mortality rates do not fully describe inequalities

in health because they do not capture the severity and length of illness and disability prior to

death. However, when health status is measured as a product of both longevity and quality of

life, the disparity between the rich and poor is much greater.

For example, across England as a whole, although people in the poorest neighbourhoods die

on average 7 years earlier than people in the richest neighbourhoods, the difference in

disability free life expectancy6

is 17 years. This means that not only do poor people generally

6 Disability-free life expectancy is the average number of years an individual is expected to live free of disability if currentpatterns of mortality and disability continue to apply.

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die earlier than their richer counterparts, but they live with sickness, illness and disability for

a much greater proportion of their life.

In Hammersmith and Fulham the gap in terms of disability free life expectancy between the

most deprived area and least deprived area has been estimated to be 9.6 years for males and

12.3 years for females. Across London, the gaps in disability free life expectancy are higher:

between the most deprived small area (in Newham) and the least deprived area (in Bromley),

it is 19.5 years for males and 15.5 years for females7

.

Children are not exempt

While inequalities in adult health may provoke equivocal reactions, a decent society would

find systemic, unfair and avoidable inequalities in child health to be unacceptable. The reality

is that children demonstrate marked inequalities in their state of health.

The Income Deprivation Affecting Children Index (IDACI) is a measure of the percentage of

children (under 16) who live in income-deprived families (i.e. in receipt of Income Support,

Income based Jobseeker's Allowance, Working Families' Tax Credit or Disabled Person's Tax

Credit below a given threshold). The index scores range from 0 (least deprived) to 0.99 (most

deprived) and every lower super output area (LSOA) in England has been ranked from 1

(most deprived) to 32,482 (least deprived).

Scores in Hammersmith & Fulham range from 0.77 (Rank - 155) in the most deprived LSOA

in the North End ward of the borough to 0.04 (Rank - 28,709) in the least deprived LSOA in

Ravenscourt Park ward. The average IDACI score for H&F is 0.36, indicating a high number

of children living in families that are income deprived.

Additionally, the Child Well-being Index (CWI) covers the major domains of a childs life

that have an impact on his or her well-being. The seven domains are: material well-being,

health, education, crime, housing, environment and children in need. By this index, H&F is

the 23rd most deprived out of 354 local authorities in England. The relevance of this data is

7 ONS experimental stats 1999-2003. Available at http://www.statistics.gov.uk/CCI/article.asp?ID=2562

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Index (IDACI), a clear gradient is seen with obesity being statistically more common among

children living in deprived areas. Ethnicity is also a factor. Children of white ethnicity have

a lower prevalence compared to children in other ethnic groups. In chapter four, we discuss

the issue of child obesity in more detail, but before that, chapter three will discuss the

challenge of tackling the upstream determinants of health which are necessary if real and

sustainable progress is to be made in reducing health inequalities.

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Chapter 3: Swimming upstream

Health inequalities are mainly a by-product of social and economic inequalities. In the words

of the Marmot Report8

, health inequalities stem from avoidable inequalities in society: of

income, education, employment and neighbourhood circumstances.

The report goes on to state that serious health inequalities do not arise by chance, and they

cannot be attributed simply to genetic make-up, bad, unhealthy behaviour, or difficulties in

access to medical care, important as those factors may be. Social and economic differences in

health status reflect, and are caused by, social and economic inequalities in society.

While there is a degree of reverse causality - people with poor health are more likely to suffer

socio-economically - the overwhelming evidence points to a range of social determinants

having a profound impact on the pattern of health and wellbeing in society. This led Marmot

to conclude that a debate about how to close the health gap has to be a debate about what

sort of society people want.

Thus, among the recommendations was a call for society to move beyond economic growth as

the primary measure of progress and development, and for well-being to be a more important

societal goal. Instead of health improvement being commonly viewed as a downstream

consequence of economic growth, the challenge would be to view economic policy as an

instrument that would be subservient to meeting social goals.

The Marmot Report also draws the line between health, economic growth and environmental

sustainability. Because of the real and present threat of ecological collapse, we need to also

rethink our concepts of human progress and development. Importantly, the report argues that

a sustainable future is compatible with action to reduce health inequalities. For example, it

notes how sustainable local communities, active transport, sustainable food production, and

zero-carbon houses will have health benefits across society.

8 The Marmot Report is the outcome of a commission established by the Secretary of State for Health in 2008. It waschaired by Professor Sir Michael Marmot and given four tasks: First, to identify the health inequalities challenge facing

England, and the evidence most relevant to underpinning future policy and action; second, to show how this evidence couldbe translated into practice; third, to advise on possible objectives and measures; and fourth, to publish a report of theReviews work that would contribute to the development of a post-2010 health inequalities strategy.

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Venturing further into the field of economic policy, the Marmot Report also warned that

simply restoring economic growth, trying to return to the status quo, while cutting public

spending, should not be an option. Economic growth without reducing relative inequality will

not reduce health inequalities. The economic growth of the last 30 years has not narrowed

income inequalities.

Two other messages are worth highlighting.

First, the social gradient in health is seen right across the spectrum. This implies that focusing

solely on the most disadvantaged will have a limited impact on health inequalities. To reduce

the steepness of the social gradient in health, actions must be universal, but with a scale and

intensity that is proportionate to the level of disadvantage. Marmot and his team call this the

principle ofproportionate universalism.

Second, there is strong evidence that the degree of social inequality is an independent

determinant of levels of average health. In other words, the worse the social inequality, the

worse the overall level of health for any given society. More unequal societies have more

unequal health outcomes andpoorer average health outcomes. Furthermore, this relationship

doesnt just hold true for health; it holds true for a range of other social outcomes including

rates of homicide, drug addiction and imprisonment.

The reason for this is that relative levels of social and economic status provoke significant

physiological and psychological reactions that can in turn negatively influence our behaviour

and bodies. The evidence and arguments summarised here have been expertly presented in a

book by Richard Wilkinson and Kate Pickett called the Spirit Level.

Can the trend of rising inequalities be reversed?

Yes it can; but not by the NHS on its own. Clinical and NHS-led interventions can only do so

much. The role of medical care is important, but limited.

While reducing inequalities in access to clinical care and preventative medicine (e.g.

screening services and immunisations) will help reduce health inequalities, it will not change

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the social gaps that underpin health inequalities. To reduce health inequalities andmaintain

health improvement, especially in the face of the present economic and financial challenges,

we need to swim upstream.

Swimming upstream

If health inequalities are largely an outcome of social and economic inequalities, it goes

without saying that their reduction requires social and economic interventions. The Marmot

report made a set of recommendations organised around six broad policy areas:

Give every child the best start in life Enable all children, young people and adults to maximise their capabilities and have

control over their lives

Create fair employment and good work for all

Ensure healthy standard of living for all

Create and develop healthy and sustainable places and communities

Strengthen the role and impact of ill health prevention

Their recommendations were also underpinned by two policy mechanisms:

Considering equality and health equity in all policies, across the whole of government,

not just the health sector

Effective evidence-based interventions and delivery systems.

Importantly, the report emphasised that delivering these policy objectives would require

action by central andlocal government, the NHS, the third and private sectors and community

groups. A particularly strong emphasis was placed on local delivery systems and local

government. According to the report, national policies will not work without effective local

delivery systems which in turn requires effective participatory decision-making at local

level, which in turn can only happen by empowering individuals and local communities.

The next section examines the key recommendations of the Marmot Report, and places them

in the context of Hammersmith and Fulham.

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Key policy recommendations from the Marmot Report

A. Give every child the best start in life

The first policy area highlighted by the Marmot Report concerns early childhood

development, care and nutrition. According to the Report, the foundations for virtually every

aspect of human development - physical, intellectual and emotional - are laid in early

childhood. What happens during these early years (starting in the womb) has lifelong effects

on many aspects of health and well-being - from obesity, heart disease and mental health, to

educational achievement and economic status.

This implies a need to ensure positive early experiences for children. Interventions later in

life, although important, are considerably less effective where good early foundations are

lacking. The importance of this recommendation for H&F cannot be over-stated given the

high number of children living in income-deprived and stressed families, as well as, the high

rate of dental caries and obesity, both of which are indicators of poor early experiences

amongst a large number of children.

Efforts to improve early childhood development need to begin in pregnancy with the

provision of good antenatal care. But it is not just the provision of clinical care that is

important. Equally important is adequate social, emotional and practical support for pregnant

women and their partners. The primary source of such support is from within families and

communities, but public services can also be important (e.g. providing information about

child care and nutrition; supporting pregnant women to stop smoking; and helping women

and couples in need with social and psychological support).

In H&F, maternity services are provided by two main acute hospitals (Imperial College NHS

Healthcare Trust and Chelsea and Westminster NHS Foundation Trust) and are commissioned

by the North West London Commissioning Partnership. Investments have been made in

recent years to increase midwifery staffing levels; improve choice of access to services and

place of delivery; and ensure the early uptake of antenatal care. To improve the continuity of

care from pregnancy, labour to the post natal period, there have been efforts to improve the

liaison between midwives (employed by hospitals) and health visitors (employed by CLCH).

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Another key intervention is the Family Nurse Partnership programme which is a dedicated

nurse-led service for pregnant teenagers and other vulnerable first time mothers, designed to

realise the benefits of early intervention during pregnancy and the first two years of the

childs life. In H&F it comprises threeFamily Nurses and some additional psychology input.

The Health Visitor service in H&F is currently constrained by a general shortage of Health

Visitors (HVs) in London. The new government has partially recognised the importance of

HVs by announcing that an extra 4,200 HVs will be trained by 2014-15. In H&F, the Health

Visitor service is incorporated into a broader Healthy Child Programme for children aged 0-5

years. At present, a multi-disciplinary team of about 20 health visitors, health visitor

assistants, childcare advisors, community nurses and administrative support provide a family

focused health promotion and parenting support programme in partnership with childrens

centres, GPs and other agencies. In order to facilitate this inter-agency and holistic approach,

the programme is organised according to six geographical clusters with named leads

designated to individual GP practices and childrens centres. There is also a community-based

child nursing service provided by CLCH which is targeted mainly at providing support and

care to children with long term conditions and disabilities.

Among the aims of the Healthy Child Programme are to improve child health outcomes

through a reduction in smoking; promoting a continuation of breast feeding; improvement in

diet and nutrition; positive parenting and family relationships; increased immunisation rates;

lower frequency of accidents; improved dental health; reduction in child abuse and neglect;

improved language and social development, and improved readiness for school. In addition,

the programme aims to improve positive parenting and family relationships and the increased

involvement of fathers.

There are currently 15 childrens centres (including designated sure start centres) which offer

a range of services to all families from pregnancy until children start at school. The idea of

childrens centres is to provide a holistic service and support mechanism for families and

carers of young children provided by close and integrated working between health, education

and social care professionals.

In addition to a range of universal and drop-in services, childrens centres also provide

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support to vulnerable children and families with particular needs (e.g. those experiencing

domestic violence or mothers with post-natal depression).

The nexus of services and facilities described above provide the basic foundation for

delivering one of the most important public health priorities: positive early child experiences.

However, the effectiveness of these services depends on three critical requirements.

First, effective inter-disciplinary cooperation and teamwork, especially between midwives,

health visitors, social care providers, educational and developmental psychologists, and other

services delivered through childrens centres. As these professionals work in different

organisations, good inter-organisational cooperation and teamwork is essential.

Second, for different disciplines and organisations to work together, an effective system is

required this includes effective and efficient protocols for communication, referrals and

sharing information; the organisation of different staff into area-based teams (ideally clustered

around childrens centres); and, an appropriate prioritisation and allocation of case loads.

Third, the quality of service provided needs to be good and to employ effective evidence

based interventions. While there are a number of performance-related indicators such as

measuring the number of contacts, visits and services provided, there is also a need to assess

the quality and impact of those services.

B. Enable all children, young people and adults to maximise their capabilities and

have control over their lives

The Marmot Reports second policy area highlights the need to maximise the capabilities of

children, young people and adolescents. Education receives special attention, based on the

evidence that educational outcomes impact profoundly on physical and mental health, as well

as future income, employment and quality of life. Central to this is the acquisition of both

cognitive andnon-cognitive skills.

The performance of schools in Hammersmith and Fulham is generally good. For example, the

percentage of students achieving 2 or more passes at A Level (or equivalent) in 2009 was

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96.6% compared to a London average of 94.8%; and the percentage of students achieving 5+

passes (grades A*-C) at KS4 (GCSE or equivalent) including English and Mathematics was

64.1% compared to a London average of 53.9%9

.

These are impressive indicators. However, it should be noted that schools in H&F include a

large number of children who come from outside the borough. In addition, we have to bear in

mind the fact that exam-based indicators, while important in their own right, do not provide a

sensitive marker of overall educational and developmental outcomes.

Predictably, there are variations in the exam performance of pupils within the borough. For

example, children who were in receipt of Free School Meals performed on average 17.3%

worse than the borough average in achieving 5 or more A* to C grades at KS4 (including

English and Mathematics).

% of Students achieving 5+ passes at KS4 (GCSE or equivalent) including English and

Mathematics in 2009 by their Free School Meals status

(Source: London Borough of Hammersmith & Fulham)

Total

Pupils

Pupils achieving 5+ A* to C

including English and Mathematics

GCSE

Number %

% Difference

from Borough

average

No Free School Meals 723 520 71.9 7.9

Eligible for Free School Meals 329 154 46.8 -17.3

Additionally, in 2009 there was also wide variation in GCSE attainment by ethnicity in the

borough. The table below shows that children from a White background generally perform

above average in comparison to the rest of the borough, while the stark difference between the

borough average and the attainment of children from a Black Caribbean or mixed White /

Black Caribbean background is particularly significant.

9 Department for Education 2009. Data available online athttp://www.education.gov.uk/inyourarea/statics/wards_lea_205_1.shtml

http://www.education.gov.uk/inyourarea/statics/wards_lea_205_1.shtmlhttp://www.education.gov.uk/inyourarea/statics/wards_lea_205_1.shtmlhttp://www.education.gov.uk/inyourarea/statics/wards_lea_205_1.shtml

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need to be a gradual shift towards an approach that also prioritises those families that may not

necessarily be high consumers of public finance but which nonetheless constitute a high risk

environment for the social and educational development of young children.

Phoenix School in White City exemplifies the potential approach that can be undertaken by

schools to improve educational, social and health in a holistic manner. It currently stands at

the top of the Government's exam league tables for improved performance. In addition to this,

as noted in a recent Ofsted report, "The Phoenix is a remarkable school: it continues to

transform the life chances of both students and their families" because it has "a deeply rooted

understanding and heartfelt appreciation" of the challenging circumstances faced by its pupils.

It therefore embodies one of the recommendations of the Marmot Report, which is that

schools should take a whole child approach to education and development, which includes

implementing full service extended school approaches, and enabling the school-based

workforce to work across schoolhome boundaries.

In Phoenix, this has been achieved in spite of considerable challenges. More than half of the

school's pupils take advantage of free school meals, and 60% are on the register for those with

special needs. Its pupil mobility rate - the total movement in and out of the school by pupils

other than at the usual times of joining and leaving - is between 25 and 30 per cent due to the

number of children forced to leave every year because they are being re-housed or because of

relationship breakdowns. Pupils at the school also speak 50 different first languages.

The school works in partnership with a range of other actors including the PCT, third sector

organisations and community groups. The police have also initiated a range of additional

initiatives aimed at developing the school as a hub for social and community development.

These include initiatives centred on sports and leisure; farming and diet; and climate change.

Engagement with families and communities is strong and facilitated by, amongst other things,

the existence of a dedicated family liaison post.

The Marmot report also emphasises the importance of quality lifelong learning opportunities

across the social gradient, by calling for the greater provision of advice for 1625 year olds on

life skills, training and employment opportunities; of work-based learning, including

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We know that patterns of employment both reflect and reinforce social inequalities and that

there are inequities within the labour market. We know that rates of unemployment are

highest among those with no or few qualifications and skills, people with disabilities, those

with caring responsibilities, those from some ethnic minority groups, older workers and, in

particular, young people, and when in work, these same groups are more likely to be in low-

paid, poor quality jobs; many are trapped in a cycle of low-paid, poor quality work and

unemployment.

The relationship between employment / work and health is set to become more important over

the next few years. Some experts currently predict the loss of half a million public sector jobs,

as well as job losses in the private sector across the country. The graph below shows that

current unemployment rates in the UK are settling around 8% (approx. 2.45 million people),

after over a 2% increase between 2008 and 2009. Unemployment rates are currently the

highest they have been for a decade and expectations are that they will continue to rise in the

short term.

Percentage Unemployment (persons aged 16-64) across the United Kingdom 1999-2010

(Source: Office for National Statistics)

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recovery through the private sector; but it remains hard to see how new jobs and opportunities

will be created to avoid further rises in unemployment and worklessness.

Hammersmith and Fulham has an economic development strategy which was published in

August 2007, and which includes a section on job creation. However, this was developed

prior to the financial turmoil and economic downturn; and requires a review and revision,

including the development of strategies such as active labour schemes which were promoted

by the Marmot Report.

This is something that the NHS itself could promote. The NHS is a great employer - as it

should be: health workers and carers form the lifeblood of any health system. As the country

moves into uncertain and worrying social and economic waters, the NHS could look at how

the health system can act, not just as a means of improving health directly, but also as a means

of improving health indirectly through its potential to maximise meaningful and socially

useful employment. In addition, the NHS provides a huge terrain within which it can offer

training or voluntary work opportunities - while not a solution to chronic unemployment, such

opportunities could nonetheless have substantial positive impacts on health and wellbeing.

There has been little evidence generated to examine how the health system can mitigate the

negative effects of unemployment. Up to now, the focus of research has been to describe the

association between unemployment and health, but with little assessment of how healthcare

interventions could prevent or reduce the negative impacts of unemployment.

For example, exploring the role of GPs and the primary care system. In Sydney, Australia,

standards have been developed for the primary care management of the health problems of

unemployed people.10

GPs trained in these standards were found to have gained confidence in

managing the problems of their unemployed patients, increased their knowledge of local

services, and disabused themselves of a number of prejudices about unemployed people.

Of importance is the notion ofanticipatory care. Rather than wait for individuals to enter into

a spiral of despair and stress which then leads to depression, alcoholism and domestic

10 Harris E, Webster IW, Harris MF and Lee PJ Unemployment and health: the healthcare system's role Medical Journal ofAustralia, 1998; 168: 291-296.

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violence, the primary care system should intervene earlier. It is easier and cheaper to

intervene early rather than to wait until health problems become more manifest and severe.

Better communication and collaboration between local service providers might enable us to

identify individuals who have recently been made unemployed, assess their vulnerability and

then implement a more pro-active set of interventions to support high risk individuals and

families before chronic and intractable problems set in. There is also evidence that short

courses / interventions to improve problem-solving skills and reduce negative feelings and

beliefs have positive and long-lasting impacts on health and future work prospects.

D. Ensure a healthy standard of living for all

The fourth policy area of the Marmot Report will only be briefly mentioned here as it relates

mostly to areas of national policy. It draws attention to the issue of poverty and living

standards. Being poor is a significant determinant of ill health. According to the Marmot

Report, there are gaps between a minimum income for healthy living and the level of state

benefit payments.

Although important steps have been made in the past to tackle child poverty, the proportion of

the UK population living in poverty has remained high, above the European Union average

and is worse than France, Germany, the Netherlands and the Nordic countries.11

The Marmot Report also talks about the taxation system in Britain, noting how the benefits of

lower direct tax rates for those on lower incomes are cancelled out by the effects of indirect

taxation. As a result, overall tax, as a proportion of disposable income, was found to be

highest in the bottom quintile. It went on to argue that the tax and benefit system needed to be

overhauled to strengthen incentives to work for people on low incomes and to increase

simplicity and certainty for families. In addition, more needed to be done to redistribute

income without harming the economy by delivering a net tax cut to people who currently face

weak incentives to enter work or to increase their low levels of pay.

11 Lundberg O, berg Yngwe M, Klegard Stjrne M, Bjrk L, & Fritzell J (2008) The Nordic experience: welfare states andpublic health. Stockholm: Centre for Health Equity Studies.

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Since the Report was published, a financial crisis which resulted in a massive public bailout

of the banking and credit regime has come and gone, leaving the country with a large public

budget deficit. Although the government has highlighted fairness in their policy

announcements, unfortunately changes to the tax and benefits appear to run in the opposite

direction to what was recommended by the Marmot team. According to the Institute of Fiscal

Studies, the overall effect is regressive and the governments budget cuts will hit the poorest

hardest.12

Marmot himself raised concerns in his acceptance speech as BMA president in June

2010. He made an impassioned plea to the medical profession to be more involved in tackling

health inequalities and social injustice.13

A short excerpt from his speech follows:

Both in research and policy I have emphasised the circumstances in which people are

born, grow, live, work, and age. These all loom larger as causes of health inequalities

than defects in our healthcare system. Heart disease is not caused by statin deficiency;

stroke is not caused by deficiency of hypotensive agents. I have emphasised not just

the causes of health inequalities - behaviours, biological risk factors - but the causes

of the causes. The causes of the causes reside in the social and economic

arrangements of society: the social determinants of health.

Commonly, when we think about action to reduce health inequalities, we debate

whether we should focus on smoking, or obesity, or immunisation. Let us remember

Halfdan Mahler, the legendary director-general of WHO. In a speech to the World

Health Assembly in the mid-1980s Mahler said: Imagine you are up to your neck in a

swamp, fighting alligators; just remember we came to drain the swamp in the first

instance.

Colleagues, if we really want to fight the alligators of health inequalities, we have to

drain the swamp. We have to deal with the consequences of an unfair set of economic

and social arrangements, and with the causes and the causes of the causes of health

inequalities.

12 Browne J and Levell P, 2010. The distributional effect of tax and benefit reforms to be introduced between June 2010 and

April 2014: a revised assessment.http://www.ifs.org.uk/publications/5246

13 Michael Marmot Speech. Available athttp://www.bmj.com/content/341/bmj.c3617.extract

http://www.ifs.org.uk/publications/5246http://www.ifs.org.uk/publications/5246http://www.ifs.org.uk/publications/5246http://www.bmj.com/content/341/bmj.c3617.extracthttp://www.bmj.com/content/341/bmj.c3617.extracthttp://www.bmj.com/content/341/bmj.c3617.extracthttp://www.bmj.com/content/341/bmj.c3617.extracthttp://www.ifs.org.uk/publications/5246

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Many of the effects of national policies that impact on the living and working conditions of

people are seen in emergency departments and hospitals, or hidden out of sight in squalid

homes, betting shops, sweat shops, or in prison. The NHS and many of the frontline services

provided by local government are fighting the alligators, and mostly doing a good job. But

Marmots call is for the health profession to work on draining the swamp as well.

There is perhaps relatively little that can be done at the local level to drain the swamp. But,

if the changes recommended by the Marmot Report are to be made, there needs to be a

paradigm shift in the way we structure and organise our society, and the development of a

broad-based social movement around health and well being. This is something that fits with

the broad democratic mandate of local government, as well as the governments ideas around

a Big Society. This public health report, we hope, will act as a small contribution to the

emergence of a more informed local discussion.

E. Create and develop healthy and sustainable places and communities

The fifth policy area of the Marmot Report concerns the physical and social characteristics of

communities. The report, for example, highlights the concept of social capital, which

describes the links that bind and connect people within and between communities. Such links

provide a source of resilience against illness through social support and networks. In the

words of the report, the extent of peoples participation in their communities and the added

control over their lives that this brings has the potential to contribute to their psychosocial

well-being and, as a result, to other health outcomes.

Building healthier and more sustainable communities also requires a healthy and sustainable

environment. At the current point in time, there may be nothing more important than

addressing the frightening prospect of climate collapse. It is remarkable how little climate

change features as a priority within the NHS. Given the failure of multilateral negotiation at

the Copenhagen Summit, as well as the limited progress at the recent Cancun Summit in

Mexico, many people are making the case that efforts to reduce carbon emissions require a

more bottom-up approach in which local governments can play a vanguard role.

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Among the recommendations of the Marmot Report are improving active travel; improving

the availability of good quality open and green spaces; improving the food environment in

local areas; and improving energy efficiency of housing - all in a way that works across the

social gradient. The report challenges local governments, and other actors, to better integrate

local planning, transport, housing, environmental and health systems, and to support locally

developed and evidence-based community regeneration programmes that remove barriers to

community participation and action, and social isolation. Key to this policy area is the local

development framework (the local spatial planning strategy).

Although few of these recommendations are concerned with core NHS budgets and

services, the Primary Care Trust has been able to initiate some projects and interventions

related to this policy area of the Marmot Report. For example, the Bike It Project was aimed

at promoting active travel by working with schools to develop a pro-cycling culture: In

schools participating in Bike It, the number of pupils cycling regularly increased from 17%

prior to the start of the project to 34.6% at the end of the first year. The project has also led to

an increase in the numbers of children who own or have access to a bike.

Such efforts by the PCT may become even more significant in light of the announcement that

funding for the School Sports Partnership will be cut. This may create a big dent in efforts

within London to support pupils to develop an active interest in sport. There is a need to

conduct a local health impact assessment of such possible cuts and to examine the full

potential of local actors to mitigate any detrimental effects.

When it comes to housing, the PCT has been working with the local authority and third sector

partners to produce a specific joint strategic needs assessment on housing and health. Limited

progress has been made thus far, and will need re-energised attention, particularly in light of

the pending cuts in housing benefit. A recent report by the Department of Work and Pensions

estimates that more than 930,000 households across the country will be hit, of which 450,000

will be families with children. The report also goes on to express concern about the potential

negative impact on child health as a result of disruption to schooling, homelessness and

overcrowding. It is unclear what the effects will be in H&F, but again, there is a need for a

health impact assessment to be conducted.

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The local food environment is also important. As will be discussed in the next chapter, the

epidemic of obesity in this country is partly the result of an obesogenic environment which

includes of a number of conditions that result in unhealthy diets. One of these environmental

conditions is the prevalence of cheap, fast-food outlets. Currently, the local public health team

is trying to engage with local fast food outlets. It has carried out a series of structured

interviews with the owners of fast food outlets; and together with the environmental health

department in the council, has started testing some popular foods to measure their sugar and

fat content. Among the findings is a lack of knowledge and understanding amongst managers

and owners about healthy food standards, but a desire to learn more. But support from local

politicians, business leaders and community leaders may be needed to generate a genuine

commitment to work on a shared agenda of improved health.

F. Strengthen the role and impact of ill-health prevention

The final policy area highlighted by the Marmot Report mainly concerns traditional ill-health

prevention programmes such as immunisations, cancer screening, health visiting and school

health services. However, the report bemoans the lack of spending by the NHS on ill-health

prevention: only 4 per cent of NHS funding is spent on prevention.

It goes on to recommend greater investment in ill-health prevention; improving the scale and

quality of medical treatment programmes; paying greater attention to public health

programmes to reduce smoking and alcohol consumption; and addressing the causes of

obesity across the social gradient.

Here in H&F, we have an effective stop smoking service; a number of services to address the

high rate of admissions and hospital attendances caused by alcohol-related harm; and

strategies and plans to improve the uptake of screening programmes and immunisation

coverage. For some years, H&F has fallen well below the national targets set for

immunisation coverage. Recently however, through improvements in the information system

and targeted approaches, we have begun to hit some of the national immunisation coverage

targets.

The governments public health white paper Healthy Lives, Healthy People has since been

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Chapter 4: Obesity - more than an issue of fatness

This chapter discusses the major public health challenge of rising levels of obesity,

particularly in children; and is also used to illustrate the need to swim upstream. There are

other health issues that also deserve attention and illustrate the need to swim upstream (for

example, mental health) but some features associated with child obesity are unique and

deserve special mention.

Overweight and obesity prevalence

The rise in levels of overweight and obesity14

is described as an epidemic for good reason

(see maps below). The World Health Organisation (WHO) estimates that in 2005, more than 1

billion people worldwide were overweight and more than 300 million were obese. Two thirds

of the worlds population now live in a country where overweight and obesity kills more

people than underweight.

The rising prevalence of obesity in boys worldwide, 1990-2006

(Source: International Obesity Taskforce)

Overweight and obesity is now one of the five leading global risks for mortality worldwide,

14 Overweight and obesity is assessed using the Body Mass Index (BMI) defined as the weight in kilograms divided by thesquare of the height in metres (kg/m2 ). A BMI in adults over 25kg/m2 is defined as overweight, and a BMI of over 30 kg/m2as obese. Measuring obesity in children is modified due to the different rates of change in their height and weight change.Age and sex-specific UK National BMI centiles classification charts are used to assess the weight of children. Thresholds fordefining overweight and obesity in children are as follows:

Overweight is defined as a BMI greater than or equal to the 85th centile but less than the 95th centile (i.e.

overweight but notobese); Obese is defined as a BMI greater than or equal to the 95th centile.

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being responsible for 5% of deaths globally. In addition, 19% of all global deaths are caused

by five diet-related risks combined with low levels of physical activity.

Within the WHO European Region, the number of obese people has tripled in the last two

decades resulting in about 130 million obese and 400 million overweight persons today. Over

50% of the adult population in the EU is now overweight or obese, and the same for about

20% of children.

Obesity is a risk factor for many conditions including cardiovascular disease, cancer and

mental illness. The impact on children is especially worrying. There is a growing incidence of

type-2 diabetes in children which was previously rare, and there are concerns about the

psychological impact of obesity particularly with regard to stigma, bullying and low self-

esteem.

Childhood obesity is also a risk factor for future adult disease. Interventions to prevent

childhood overweight and obesity should therefore also be encouraged as a means of

preventing a large proportion of our current children from experiencing a future life of

chronic ill health.

There are also economic impacts associated with obesity and overweight, which are estimated

to have cost the NHS 55.4 million in 2010 for the management and treatment of diseases

related to obesity15

. These figures are for NHS expenditure only and exclude the wider

societal costs of lower productivity, lost output, increased level of morbidity and increased

social care needs associated with overweight and obesity.

The Causes of Obesity

Understanding the causes of obesity are critical because the treatment of obesity is at best

difficult. Obesity needs to be prevented.

15

The costs have been estimated using the national estimates calculated by Foresight. A microsimulation model was usedto forecast costs to the NHS of the consequences of overweight and obesity. No inflation costs, either of prices generally orhealthcare costs in particular, were incorporated within the costs, so this allows for direct comparison to current prices.

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At the simplest level, obesity results from a positive energy imbalance: more energy goes into

the body than is burnt off. Energy intake is determined by eating-related behaviours which are

in turn determined by social, cultural and environmental factors. Similarly, environmental

factors influence the extent to which individuals are able to burn off the energy they consume.

The importance of social factors is highlighted by the consistent social gradient in the

prevalence of obesity. It has been estimated that 20-25% of the obesity found in men, and 40-

50% of the obesity found in women in Western Europe can be attributed to differences in

socio-economic status.

Not infrequently, obesity has been labelled a disease of affluence. In reality, within high-

income countries, obesity and overweight is concentrated amongst the poor. Several studies

have found that the food eaten by economically poorer individuals is higher in energy, lower

in micronutrients and contain less fruit and vegetables. Children from poorer families tend to

drink more soft drinks; and physical activity levels among adults and children in lower socio-

economic groups is lower as well. But even in poor countries where under nutrition and

hunger is prevalent, obesity is becoming a problem, causing such countries to suffer from a

double-epidemic.

Obesity is also commonly referred to as a lifestyle disease but explanations focused on

individual lifestyle choices around diet and exercise are inadequate. It is necessary to

understand obesity as a social and collective problem, rather than just an individual problem.

The diagram below provides a useful representation of how child obesity is the outcome of a

set of complex biological and social factors that operate at multiple levels - from the level of

the human cell, to the individual and his / her family, through to the level of society more

generally. Fatness is about far more than just eating and exercise.

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Systems Map of Obesity(Source: Foresight Systems Map)

There is still much that we remain unsure of regarding the pattern of the obesity epidemic. For

example, why are fat mothers associated with fat daughters, but not fat sons? And why are fat

fathers more closely associated with fat sons rather than fat daughters?

We know that genes play a role by causing some individuals to have a greater propensity to

becoming overweight or obese. There isnt anything like a fat gene that makes obesity

inevitable; but some role is played by our genetic inheritance. As a species, our genetic

predisposition to obesity has been shaped over millions of years and cannot explain the

sudden explosion of fatness in society. Environmental factors play a big role. This includes

the immediate biological environment of genes, especially in utero and in early childhood.

Epigenetic factors are things that interact with genes and which can cause them to be switched

on or off. A foetus with a genetic propensity for adult disease will have a higher risk of

actually becoming diseased ifexposed to stress or maternal diabetes during pregnancy. The

same principle applies to the genetic propensity for becoming fat.

When it comes to growth patterns in childhood, there is also some evidence that the trajectory

is largely determined by the time children reach the age of 5 years. The implication of this is

that preventative strategies are best aimed at pre-school children and their families. This also

implies that in order to prevent child obesity, adults need to be targeted.

Linked to the importance of early childhood is the role of breast-feeding in protecting against

obesity in adulthood. One study found a 4% risk reduction of being overweight in adult life

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for each additional month of any breast-feeding in infancy. Breast-feeding is therefore good

for both child and adult health; exclusive breast-feeding in the first months of life is much

better than partial breast-feeding. However, the prevalence ofexclusive breast-feeding until 4

months is low in the UK, especially when compared with other European countries. In

Hammersmith and Fulham, the exclusive breast-feeding rate at six weeks is 45-55%.

However, nearly a quarter of six week old babies are not breast-fed at all in the borough.

Low levels of physical activity and sedentary behaviour have also been implicated. Physical

activity helps to burn calories, which in turn can help prevent weight gain. However, once

children have become fat or obese, increasing physical activity is not always an effective

means of losing weight. Children who are obese find it difficult to sustain physical activity

due to factors at the cellular and biochemical level; rarely are children fat and inactive

because they are lazy. The implication, once again, is that we need to prevent obesity; not

treat it; with a strong emphasis needing to be placed on energy intake in early childhood.

The limited impact of physical activity on reducing weight does not mean that physical

activity is an unimportant element of child health. Healthy levels of physical activity

contribute to improved physical and emotional health in many other ways.

The genes we have inherited from our ancestors were shaped over hundreds of generations in

an environment that is completely different from the one we have now. Of importance, is the

widespread availability and consumption of high-calorie foods and drinks with high sugar;

products that are well marketed, cheap, ubiquitous and addictive. It is therefore important to

avoid trivialising obesity as an outcome of personal choice.

We also know that psychological processes are at play. For example, recent research suggests

that many individuals develop behaviours that are learnt or mimicked from those around

them. We eat the way other people eat, and this may help explain some of the social

clustering of obesity. For young children, this mimicking effect may mean that healthy eating

patterns can often only be properly established through interventions targeted at families; and

for older children, the over-consumption of sugar, salt and fat may need to be tackled through

interventions aimed at entire peer groups and not individuals.

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Child obesity in H&F

In Hammersmith and Fulham, about one in eight children in state school reception year and

about one in four in state school year 6 are obese. These rates are similar to national and

London-wide averages. However, they only apply to children in state schools. About 30% of

pupils in Hammersmith and Fulham go to private schools for which we have no data;

however, it is likely that the prevalence of obesity in these children is lower than those in state

schools.

Boys tend to be more overweight and obese compared to girls; and rates of overweight and

obesity are higher in the Caribbean and Black African ethnic group compared to the Whiteethnic group

16

17

. There is also an association between deprivation and obesity, especially

amongst children in reception year.

Prevalence of obesity in reception aged pupils(Source: NHS Information Centre, 2008/09)

16 Sproston K, Mindell J. Health Survey for England 2004. Volume 1: The health of minority ethnic groups.London: TheInformation Centre for Health and Social Care; 2006.

17 The Information Centre, 2009, National Child Measurement Programme: England, 2008- 09 school year NCMP report2008-9

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Prevalence of obesity in year 6 aged pupils (Source: NHS Information Centre, 2008/09)

The high prevalence of obesity is corroborated by other data such as the poor state of oral

health amongst children which is caused in some part by poor diet, especially the

consumption of sugary drinks.

Preventing Childhood Obesity

It is hard to treatchildhood obesity. And it is hard to reverse the long-term negative effects of

poor nutrition in childhood. Furthermore, the ill-effects of over-consumption of sugar and fats

impact on children before they become obese. This points to the need for a more effective and

better resourced prevention agenda.

This in turn points to the need for a societal approach aimed at changing the obesity-

generating environment. Most important are efforts to improve food and eating patterns less

sugar and fewer unhealthy fats, especially in the early years; and more exclusive breast-

feeding in the first six months of life.

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While there is a need to promote healthy eating choices; more effort also needs to be aimed at

discouraging the production and availability of unhealthy foods, and doing the opposite with

healthy foods.

On the whole, people are generally informed of the danger of being overweight. There is a

good level of awareness about healthy and unhealthy diets. Most people are aware of the

recommended five fruits and vegetables a day. What is more difficult to change are habits and

behaviours, as well as the social, cultural and environmental barriers to the adoption of

healthy shopping, cooking and eating. For large sections of the population, life is high-

pressured, fast-paced, stressful and insecure; and unhealthy eating is part of the coping

mechanisms of many people. Food with lots of sugar provide comfort; greasy fast foods

provide convenience and affordability; and trans fats help provide longer shelf and fridge

lives for food.

Much needs to be done with families and communities through nurseries, childrens centres,

schools and other locations; but there is also much to be done with upstream interventions

aimed at the food industry as well as through urban planning. The Foresight report from 2009,

commissioned by the government to produce a long-term vision of how to tackle obesity,

emphasised that efforts should not be over-reliant on individual responsibility or fragmented

short term initiatives, but that a shift in society and the environment as a whole was required.

Similarly, the BMA has noted that in order to halt the obesity epidemic, interventions at the

family or school level will need to be matched by changes in the social and cultural context so

that the benefits can be sustained and enhanced18

.

One public health nutritionist made the point more strongly by saying that we should not kid

ourselves into thinking that the obesity problem will be resolved without fundamental change:

.an earthly cynic, might suggest that obesity actually contributes positively to the global

economy (greater food consumption, bigger clothes, labour-saving devices, motorized

transport, even incomes generated by variably effective treatments and token gym

memberships). All of these create wealth. Therefore, it is not surprising that prevention

budgets are orders of magnitude less than the marketing of budgets for individual carbonated

18 BMA, Preventing Childhood Obesity, 2005;www.bma.org.uk

http://www.bma.org.uk/http://www.bma.org.uk/http://www.bma.org.uk/http://www.bma.org.uk/

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drinks or chocolate bars, or that sports fields are sold for building, roads are widened

without cycle or pedestrian tracks and that portion sizes increase. Are current efforts at

obesity management and prevention expressions of cynical tokenism?19

So what can and should be done? There are no magic bullets to address this problem. As

described earlier, the causes are multi-factorial and the solutions involve a mix of

interventions and policies, and a wide range of actors. If we treat child obesity not just as a

health problem in its own right, but also as a marker of other health needs (e.g. poor oral

health, poor child care and psychological / emotional ill health), there are grounds to identify

child obesity as a social and public health priority which needs to be tackled.

In light of this, we propose that the local NHS and council in H&F organise a health summit

in 2011 to discuss, debate and develop an agenda for tackling childhood obesity. This should

involve experts in the field; practitioners, councillors; and members of the public. Such a

summit should not just be a high profile talkshop; but rather a moment during which

commitment to bold action is galvanised. It should therefore be preceded by several months

of preparatory work.

19 M E J Lean, Childhood obesity: time to shrink a parent (Editorial) International Journal of Obesity34, 1-3 (January 2010)

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Chapter 5: General Practice - a platform for more

Introduction

Approximately 355 million of NHS money is spent on Hammersmith and Fulham residents.

A large proportion of this funding is spent on hospital services (see below).

Budget allocations across service sectors in Hammersmith and Fulham

Financial Year 2010/11

Some of the spend in hospitals is for the treatment of conditions that could either be prevented

or managed more cost-effectively in the primary care setting. There is also an amount of high-

cost expenditure on patients during the terminal stages of their lives, some of which may be

inappropriate or unwarranted; and on certain high cost drugs of questionable value.

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Money spent in one part of the NHS means less money available elsewhere and there is an

argument that the NHS budget could be better used if more of it were directed at more cost-