Kevin Fenton (Public Health England)
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This document discusses emerging approaches and lessons for making an impact on public health and wellbeing in England. It notes the increasing life expectancy but decreasing healthy life expectancy. Key health challenges include non-communicable diseases driven by risk factors like diet, tobacco, and obesity. Opportunities for improving health include prevention focused initiatives, place-based approaches, integrating health and social services, and empowering communities and individuals. Public health requires a whole system approach and partnership across many sectors.
Kevin Fenton (Public Health England)
- 1. Making an impact on the public's health and wellbeing in England: Emerging Approaches and Lessons November 2017 Professor Kevin Fenton Snr. Advisor, Health and Wellbeing Public Health England Director of Health and Wellbeing, London Borough of Southwark Twitter: @ProfKevinFenton Email: [email protected]
- 2. Contents • Understanding today’s health challenges • Why a renewed focus on prevention and public health is needed • What are the opportunities and enablers • Envisioning a future for public health 2 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 3. Health and wellbeing in England today. What are the issues?
- 4. Life expectancy is increasing Making an impact on the public's health and wellbeing in England Between 1990-2013, life expectancy in England saw a 5.4 year increase from 75.9 to 81.3 years (one of the biggest increases in EU15+ countries). This is mainly due to falls in the death rate from CVD, stroke, COPD and some cancers. @ProfKevinFenton
- 5. But what about healthy life expectancy? • While life expectancy has increased, this hasn’t been matched by improvements in levels of ill-health. • So, as a population we’re living longer but spending more years in ill-health. For several conditions, although death rates have declined, the overall health burden is increasing. For example: • Death rates from diabetes fell by 56%, but illness and disability associated with diabetes went up 75%. • Sickness and chronic disability are now causing a much greater proportion of the burden of disease • Low back and neck pain is now the leading cause of overall disease burden. Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 6. Understanding the NCD Challenge GBD: Leading causes of DALYs 1990 & 2013 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 7. Making an impact on the public's health and wellbeing in England Understanding the NCD Challenge Leading risk factors driving DALYs 2013 1. Dietary risks 2. Tobacco smoke 3. High body mass index 4. High systolic blood pressure 5. Alcohol and drug use
- 8. Southwark is an exciting and challenging place in which to take on modern public health problems THE LONDON BOROUGH OF SOUTHWARK 310,000 people – very young and with 55% BME population Diverse in terms of culture and socioeconomic outlook: Dulwich, Camberwell, Peckham, London Bridge and Canada Water Regenerating rapidly with new office space and housing stock Growing with 37,000 more people expected in the next decade But there are major health and care challenges: High levels of population turnover London-wide challenges around housing availability, quality and cost Hollowing out of the middle: with extremes driving luxury flats vs. social housing and benefits High levels of mental health problems, cardiorespiratory disease and unhealthy weight, and significant pressures on sexual health services 12% Population increase by 2026 4715 Births in 2016 1148 Deaths in 2016 193 Net migration in 2016 229 Population turn over per 1,000 residents in 2014-15
- 9. Slide 9 Adding life to years should be our public health ambition Slide 6 PUBLIC HEALTH INDICATOR DASHBOARD Note: The arrow indicate the direction of travelling for a specific indicator and the colours show if that indicator is improving, is stable/worsening and/or is worse than average. The slide to be considered as part of the entire PH indicators dashboard slide deck
- 10. What about health inequalities? • While life expectancy has increased overall, there has been little, if any, improvement in inequalities: • By 2013, those living in the most deprived areas are only just approaching the levels of life expectancy that less deprived groups enjoyed in 1990. • More deprived groups are affected proportionally more by disease risk factors than less deprived groups. The types of disease and risk factor are roughly the same across all deprivation areas however. • While the data highlights regional differences in life expectancy and disease burden, inequalities are actually greater within regions than between them - so largely related to deprivation not geography. Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 11. Understanding the NCD challenge The wider determinants of health Getting serious about prevention11 Making an impact on the public's health and wellbeing in England @ProfKevinFenton • While individuals’ behaviours do matter (for example, studies show around half of the health inequalities between rich and poor are the result of smoking), the reality is that our health is impacted by a range of wider determinants including: • Good start to life • employment • higher educational attainment • safe, supported, connected communities • poor housing and homelessness • living on a low income • social isolation, exclusion and loneliness • stigma and discrimination
- 12. Only one of these two Southwark children born this year will see New Year’s Eve into the 22nd century Reference: Annual Report of the Director of Public Health.
- 13. The role of public health “The activities that ensure conditions in which people can be healthy. These activities include community wide efforts to identify, prevent, and combat threats to the health of the public. “ - Institute of Medicine Definition of Public Health 13
- 14. Responding to the challenge Confidence in public health’s USP and value add 1. Monitor the health status of the community. 2. Investigate and diagnose health problems and hazards. 3. Inform and educate people regarding health issues. 4. Mobilize partnerships to solve community problems. 5. Support policies and plans to achieve health goals. 6. Enforce laws and regulations to protect health and safety. 7. Link people to needed personal health services. 8. Ensure a skilled, competent public health workforce. 9. Evaluate effectiveness, accessibility and quality of health services. 10. Research and apply innovative solutions. 14 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 15. Responding to the challenge Confidence in selecting and combining interventions Making an impact on the public's health and wellbeing in England 2. Clinical interventions 3. Long lasting protective interventions 4. Changing the context to make individuals’ default decisions healthy 5. Socioeconomic factors Increasing population impact Increasing individual effort needed 1. Counselling and education Changing the context could have more potential, but takes time to realise. Proposals so far include tackling diet and alcohol. Focus to identify savings to the NHS in short-term, incl. tackling 1) alcohol and tobacco consumption, and 2) diabetes and hypertension.
- 16. Responding to the challenge Confidence in our advocacy for multi-level interventions 16 Making an impact on the public's health and wellbeing in England
- 17. Our priorities for public health action Emerging priorities for Southwark Public Health Slide 6 of 12 Priority Area for action 1 Social Regeneration: Making urban regeneration work for all communities 2 Better Care for All: Supporting the creation of sustainable, high quality, and effective local health and social care systems 3 Improving Health Outcomes: Improving health, wellbeing and tackling inequalities for all of Southwark's residents 4 Making health everyone’s business: Developing and expanding a health in all policies approach in Southwark 5 Investing in our staff: Making the Southwark the best place to work for our staff and partners Our strategic priorities are supported by 3 core values: (1) Tackling inequalities (2) Promoting effective partnerships (3) using data and evidence to inform practice and policies
- 18. Opportunities and enablers for improving health and wellbeing 18
- 19. The Five Year Forward View (5YFV) Calls for a radical upgrade in prevention • A whole systems approach to tackling rising obesity rates • Diabetes Prevention Programme – an intervention to improve the health of patients at imminent risk of developing type 2 diabetes • Population behavioural change through engaging and activating patients to manage their own health • Housing and health – ensuring the right home environment to promote health and wellbeing across the life course • Tackling health related worklessness – work as a clinical outcome that benefits patients 19 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 20. Responding to the challenge Whole-system approachesto tacklingobesity We need a broad range of actions across a wide range of players: • Reformulation of food and drink • Fiscal measures to reduce unhealthy food consumption • Restrictions on advertising and promotions • Enhanced planning powers • Government Procurement Standards for food in public sector organisations • Access to weight management services • Public campaigns to support healthier choices • Promotion of activity (as part of healthier lifestyle) • Leadership to tackle the new social norms • A wide coalition with industry and opinion formers Getting serious about prevention20 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 21. Responding to the challenge Housing and health • Health begins at home • The right home environment is essential to health and wellbeing, throughout life. • Key features of a home in which to start, live and age well: • Warm and affordable to heat • Free from hazards, safe from harm • Enables movement around the home and is accessible • Promotes a sense of security and stability • Support available if needed 21 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 22. Responding to the challenge Work and health • Good work is good for health; being out of work is bad for health • 28% of the working age population have a health condition or disability and 40% (4.5m people) of those are not in employment • The NHS directly employs around 1.2 million people in England. • Staff health and wellbeing has a direct impact on patient outcomes as well as sickness absence and agency costs. • PHE is working with NHS England and 12 NHS providers, including CCGs and the GP federation, to develop a response: • Using the Workplace Wellbeing Charter as the road map for implementing NICE guidance • Rolling out NHS Health Checks for NHS Staff through NHS Occupational Health • Tackling the food and physical activity environment across NHS settings 22 Making an impact on the public's health and wellbeing in England @ProfKevinFenton
- 23. Responding to the challenge Place based approaches for improving health • By integrating health, local government, housing and other services across a geographic area, it is possible to reengineer the system to secure better outcomes and become sustainable for the future. • There has been ongoing policy focus on trying to integrate commissioning and provision of health and care services through a variety of initiatives such as: • Better Care Fund (BCF); Co-commissioning of primary medical care and specialised services • Accountable care organisations/ systems • Overlaid and joined up with these initiatives, devolution provides further opportunity to deliver services and support joined-up around people’s needs. 23 Making an impact on the public's health and wellbeing in England
- 24. Public Health: Past, Present and Future
- 25. Public Health: Past, Present and Future Achievements of the 20th century: • Vaccinations • Improved sanitation • Fewer deaths from heart disease and stroke • Healthier mothers and babies • Reduction in tobacco use Emerging threats of the 21st century: • Chronic diseases • H1N1 • New and re-emerging infectious diseases • Natural disasters • Climate change
- 26. Public Health is everyone’s business Different actions for different outcomes • Prevention. By 2020/21 we will have seen a move to a more concerted focus on prevention and improving healthier life expectancy for all. • Devolution. We will have grasped the opportunities that devolution and a move to a place based focus presents and mitigated any risks. • Integration. Action will be being taken at all levels from the local to the national. There will be recognition that no one level working alone will solve the major public health issues present in our communities and that national and local government have different but complementary roles to play. 26 Making an impact on the public's health and wellbeing in England
- 27. • Empowerment. Individuals and communities will be being supported in taking action to remain healthy using an asset based approach. Health protection safeguards will remain in place and the population will continue to have access to high quality screening and immunisation services. • Leadership. Both nationally and locally there will to be effective systems leadership, co-production and action across the public sector, working with and for communities, in tandem with the third and private sectors. • Culture. A new culture will be developing with system leaders behaving and working together in ways that ensure place based action is supported and being nurtured. 27 Making an impact on the public's health and wellbeing in England Public Health is everyone’s business Different actions for different outcomes
- 28. What does this mean in practice? PUBLIC HEALTH IS EVERYONE’S BUSINESS • Schools • Employers • Town planners • Housing • Social services • Blue light services • Parks • Leisure services • Transport • Community groups and local charities • Environmental Health 28 Making an impact on the public's health and wellbeing in England
- 29. What does this mean in practice? OUTCOMES BASED COMMISSIONING A system that incentivises and rewards hospital-based activity Where contracts are allocated against specific care pathways that may neglect those with multiple morbidities A system that’s remote to patients involving multiple providers operating across unintuitive geographies Where conditions are treated and there’s no explicit reward for prevention or self-management Providers will work together and patients shouldn’t even notice institutional boundaries Accountable systems of care promote good physical health alongside positive wellbeing Where the financials reward organisations for preventing disease rather than treating it And where services are local and sensitive to areas to which patients instinctively relate.
- 30. Conclusions • Although the prevention challenge is immense, it is achievable, taking a population and life course approach • Implementing those interventions requires local health, care and community partners to work well together and put the achievement of outcomes for local communities as the major purpose that binds them together. • Aligning the shared ambitions with local proposals from Health and Wellbeing boards and devolution/combined authorities. 30 @ProfKevinFentonMaking an impact on the public's health and wellbeing in England
- 31. Making an impact on the public's health and wellbeing in England: Emerging Approaches and Lessons November 2017 Professor Kevin Fenton Snr. Advisor, Health and Wellbeing Public Health England Director of Health and Wellbeing, London Borough of Southwark Twitter: @ProfKevinFenton Email: [email protected]
Editor's Notes
- #4: Many people in Hampshire benefit from good education and employment, good housing and a great environment. But there is significant inequality in the health outcomes experienced between the most and least deprived people in our communities.
- #5: This slide shows life expectancy at birth by gender in Australia, Sweden, Italy, England, Finland, Portugal and US, and compares LE in 1990 and 2013. Women continue to have a longer LE than men, but overall LE has increased.
- #7: This slide shows the change in the rankings of NCDs between 1990 and 2013. Heart disease was the top cause of DALYs back in 1990, it has been replaced by MSK, low back and neck pain. Dementia is up from 9th to 6th position.
- #12: The wider determinants, such as employment, education also have an impact on people’s ability to feel they have control over their health. This can make it difficult to become a citizen health expert. The WHO Europe (2013) Review of social determinants and the health divide: “How people experience social relationships influences health inequities. Critical factors include how much control people have over resources and decision-making and how much access people have to social resources, including social networks, and communal capabilities and resilience.” (p.13) A National Institute Health Research funded systematic review and meta-analysis of community engagement and health inequalities - 315 effectiveness studies concluded that community engagement interventions are effective at improving health behaviours, health consequences, participant self-efficacy and perceived social support for disadvantaged groups (O’Mara-Eves et al 2013)
- #15: The 10 Essential Public Health Services describe the activities that should be undertaken in all communities. They provide a working definition of public health and a guiding framework for the responsibilities of local public health systems. The practical examples that I shared a few moments ago, all fall under these key functions of public health and you can easily tell where each earlier example fits here.
- #16: Source: Frieden, T. R. (2015); The Future of Public Health; The New England Journal of Medicine; 2015 373:1748-1754
- #17: Notes: 1. National interventions are effective and PHE will continue to utilise the best available evidence to implement sustained work. 2. Plain Standardised Packaging is a brilliant achievement! 3. The continued delivery of proven national mass media campaigns is also effective for reducing smoking across the population of England and we remain committed to maximising the impact and reach of these campaigns.
- #20: Perhaps reference Carl Petrokofsky’s recent trip to Hampshire to talk about obesity
- #22: PHE brought partners together and continue to provide a leadership role in this Impact on health care & social care Poor condition housing - up to £2.5bn p.a. NHS Single homeless – at least £85.6m p.a. NHS
- #26: Since 1900 the average American lifespan has lengthened by 30 years and 25 of those years are attributable to public health. A few of the major public health achievements of the 20th century include: Population-wide vaccination programs which have not only eradicated Small Pox but also controlled the spread of numerous communicable diseases including measles, diphtheria, rubella, and tetanus, among others. - Improved sanitation has dramatically reduced spread of infectious diseases such as Cholera and Typhoid. Through public health prevention efforts such as smoking cessation programs, blood pressure control, and early detection, death from coronary heart disease has decreased by 50% over the past four decades. Increased access to antibiotics and health care coupled with better hygiene resulted in a 90% decrease in infant mortality and 99% decrease in maternal mortality since 1900! Millions of cigarette smoking related deaths have been prevented due to public health anti-smoking campaigns and cessation programs. Despite these many advancements, we still have a ways to go in protecting the health of our population and many challenges ahead. [ADD a bullet or replace the provided ‘emerging threats’ with statistics illustrating health concerns specific to your county and talking points in the script describing the statistics. For assistance in obtaining county specific statistics, visit the Community Health Status Indicator (CHSI) website at http://www.communityhealth.hhs.gov and search for your state and county to view county specific health indicator statistics].