Two independent watchdogs are calling for a renewed drive to improve public health services after analysing the success of policies over the past decade.
A new report by the Healthcare Commission and Audit Commission assesses the impact government policy has had on: narrowing health inequalities; improving sexual and mental health; and reducing smoking, alcohol misuse and obesity.
It finds the government’s ambitious public health programme has helped significantly improve overall life expectancy and reduce mortality from the big killers. Between 1996 and 2006, premature deaths in under-75s from circulatory diseases fell 45 percent and those from cancer dropped 15 percent.
There have also been advances in tackling smoking and improving sexual health, two areas where health inequalities are significant.
While smoking remains England’s single greatest cause of preventable illness and early death, the number of people who smoke has fallen considerably in recent years. Research suggests that 400,000 people have given up smoking since the ban was introduced in July 2007.
Teenage conceptions are at their lowest level in over 20 years and there is better access to genitourinary medicine services and chlamydia screening, although progress in relation to contraceptive services has proved challenging.
But these rates of improvement have not been matched in the areas of alcohol misuse and obesity.
In England, which has the fastest rising rate of childhood obesity in Western Europe, a third of school age children are overweight or obese.
Deaths associated with alcohol consumption have risen. In men, the death rate doubled from 9.1 deaths per 100,000 in 1991 to 18.3 in 2006. For women, the rate increased from 5.0 to 8.8 deaths per 100,000 over the same period, a rise of around 80 percent.
If the trends continue, alcohol and obesity will have an increasingly profound effect on public health and service delivery, the report says. The steep rise in the number of people who are overweight and obese or suffering from alcohol related illness could reduce the impact on mortality rates of recent improvements in heart disease and cancer, plus increase rates of diabetes and hypertension.
The report comments that a 2004 national strategy to tackle alcohol was not accompanied by clear measurable objectives or a systematic programme to drive change through the system. As a result, improvement at a local level has been inconsistent. Similarly, there was no national strategy to tackle obesity across the whole population until 2008. This programme must remain a priority as it will require sustained effort and resources to deliver.
On life expectancy, the report says boys born between 2004-2006 can expect to live to 77, three years longer than boys born in 1991. Girls born during the same period are living two and a half years more than those born in 1991 - to 81 and a half years of age.
But health inequalities are not narrowing with differences around the country and between manual and non-manual workers. From 2004 to 2006, life expectancy for men was lowest in Manchester - at 73 years - and highest in Kensington and Chelsea - at 83 years. The life expectancy gap has not closed over the last decade.
The Commissions welcome the government’s plans to improve public health, set out in Lord Darzi’s recent review, and point out that their report includes important lessons for the future.
Targets have brought some success, but the report says the government should build on the lessons learned from tackling teenage conceptions and smoking. In these cases, a comprehensive range of approaches was used, rather than relying on targets alone to drive improvement.
Key points in the future for national, regional and local bodies are:
- setting clear, ambitious and measurable objectives, backed up with relevant, reliable and up-to-date information
- consistent policies across national government and at regional and local level and involve parts of the systems working together
- local action backed by evidence of ‘what works’, with resources, staff and skills to deliver
- the drive for delivery is sustained without the distraction of further national policy or structural changes.
The report also says that it is critical that Local Strategic Partnerships (LSPs) – made up of local councils and primary care trusts and other local organisations – work effectively to ensure the efforts to improve health and tackle health inequalities are a success.
The Commissions say it is encouraging that many local areas have chosen to make health improvement – such as reducing obesity, teenage pregnancy and smoking – a priority as they draw up local plans (local area agreements). But the report says that public health experts were concerned that some areas may not prioritise important aspects of public health. The Commissions point out that the forthcoming Comprehensive Area Assessment, a new system for assessing the performance of public services in a particular area, will encourage joined up action from the variety of local bodies involved.
Anna Walker, the Healthcare Commission’s Chief Executive, said: “The government has begun to tackle the big killers but more needs to be done on some of the main issues affecting our health such as obesity, alcohol and smoking. The government should also apply lessons learned from its most effective programmes to ensure that the problems of obesity and alcohol misuse do not derail health improvement in the future. We do not want to see any reversal of the health gains that have been made. Health inequalities also remain a challenge.
“We are very pleased that our survey of directors of public health shows that regulation is playing an important role in ensuring that health as well as healthcare is a key issue for NHS trusts. People want help with maintaining their health as well as care when they are ill.”
Steve Bundred, the Audit Commission’s Chief Executive, said: “It is clear that local authorities, together with the NHS and other local partners, will have a big role to play in tackling health inequalities. Stopping people smoking, reducing teenage pregnancy and cutting child obesity are local priorities they have agreed with central government. Through the development of the comprehensive area assessment, the Audit Commission and Healthcare Commission will be working closely with councils and primary care trusts to help them to deliver and achieve these outcomes.
“We owe it to our children to look at the lessons of the past ten years to help us focus on the challenges facing public health issues over the next ten years.”
Case study – Hackney in London
City and Hackney Primary Care Trust serves an area with high levels of deprivation. In 1998, it had the fourth highest rate of teenage conceptions. By 2008, the area had reduced its teenage conception rate by a third. The area was part of a national programme to reduce teenage conceptions, which included a national target, a local coordinator, a local coordination board, financial resources, targeted prevention initiatives and strong performance management. The London Borough of Hackney is the local authority area with the highest percentage of obese children entering reception year, according to the Department of Health’s Health Profiles in England. Obesity has not benefited from the same level of national focus or local action as teenage conceptions over the ten-year period.
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