There is a telling sentence in Middlesbrough’s Health and Wellbeing strategy that exemplifies the extent of the wide inequalities in health we face here. ‘The starkness of inequality can be observed from the top of Ormesby Bank: for every mile travelled from Nunthorpe to Pallister, there is a two-year reduction in life expectancy.’
And this is a town where life expectancy is lower than the average for the North East and England. From 2006 to 2010, the life expectancy gap between the most deprived and least deprived electoral wards in town was 14.8 years for men and 11.3 years for women. This was worse when compared with 12.4 years for men and 9.5 years for women for the years 2001 to 2005.
We are a relatively new town - only recently celebrating our 160th birthday - and we have a very stationary population which means we are not that genetically diverse. A lot of families came from South Western Scotland and Ireland to work in the steel, coal and chemical works which led to the town being described in the 1870s by Prime Minister William Gladstone as the Infant Hercules.
Now the coal and steel are long gone and unemployment remains a major challenge particularly among the young. The number of fuel-poor households is increasing and homes in disrepair are occupied by some of the most vulnerable families. Over 75% of people aged over 65 known to social care have a disability.
The people from Ireland and Scotland and brought with them a terrific propensity for ischaemic heart disease. So It’s unique: a new town with a propensity for heart disease which is I think only second to Glasgow.
Middlesbrough ranks in the bottom ten of the most deprived areas in the country; there has been an increase in the risk to health and wellbeing due to the economic downturn and welfare reforms, levels of educational attainment are generally poor, many people are on benefits, and domestic violence remains a significant issue with reported levels double the national average.
Nihilism
Sad to say in many people there are a lot of entrenched ideas and a sort of built in nihilism. There is a mindset that says ‘I am only going to live till I am 58 because that’s what all my family live to so I might as well smoke. I will live for today and the NHS will sort me out’.
We really need to change those nihilistic mindsets and we need to make some starts in education and that is where we need to work with local authorities. The key drivers of ill health: bad housing, unemployment, poor educational attainment, drug and alcohol abuse are social problems which require the input of local and national government, the criminal justice system, charities and the voluntary sector. Now that local authorities have a public health remit those ties are more crucial than ever in ensuring our goals and priorities can be attained.
Strategy
Our health and wellbeing board which is chaired by the high profile Middlesbrough Mayor Ray Mallon, has become the focal point for health planning. Assessing the health and wellbeing needs of the local population was carried out through the Joint Strategic Needs Assessment (JSNA) and formed the basis of our Joint Health and Wellbeing Strategy. The strengthened role of JSNAs and HWS will, I feel, enable local councillors, CCGs, the NHS commissioning board, directors of public health, adult and children’s services, NHS providers, voluntary and community sector and partner agencies to better work with together.
The HWS is a ten year plan with the simple aim ‘To improve the health and wellbeing of our local population and reduce health inequalities’. The document sets out a whole range of aims to improve health and wellbeing by not only improving prevention, detection and treatment but also across the wider determinants of health, better education, housing, employment and reducing crime and improving the environment. The document is not crammed with targets and figures. It does not promise to reduce cardiovascular deaths by x per cent, rather it states that ‘fewer people will die prematurely from preventable causes’ and that ‘more people will live longer and healthier lives’.
For the JSNA to work it must be a living document and we must be able to reach in and use it as a lever. There is a lot of box-ticking going on but if we really want to change anything, we do have to transfer that box-ticking into tangible things.
In Middlesbrough, it’s nothing new for the health economy to work with the local authority. We have always ensured that the local authority was represented on our CCG under practice-based commissioning where we involved them with any major decisions.
Joined up working is vital when you are designing initiatives like Get Active on Prescription which means we can refer patients to a 12 week programme of light physical activity run by the council’s sport and leisure department. We need to do more of the same, working even more closely together. For example when we advise people to take up their bikes and exercise, we need to make need to make sure there are cycle lanes and if we advise swimming, there are swimming pools available.
Alcohol
We already work closely with the drug and alcohol team because alcohol-related admissions to our hospitals are the fourth highest in the country.
Ray Mallon estimates that the production, distribution and sale of alcohol may contribute as much as £65 million pounds to the local economy, but the costs will be well over £50 million in terms of A&E, police and environmental impact.
We are a very conscious of the fact that alcohol is a major driver of the economics of our town so there are challenges around that. I haven’t got an easy answer to reducing alcohol consumption without having an impact on the local economy. But I think that for alcohol-related behaviour to become more socially unacceptable a tougher policing line would help as would making it pricier but we can’t make it too pricy that people would go to the town next door - pub and club owners would fight that.
We also need hard-hitting campaigns, perhaps showing people the video of how they behaved the next morning would be interesting. Certainly when parents are alcohol dependant what brings them to their senses is seeing children saying ‘you were throwing up and incontinent’ is extremely embarrassing for any parent and might buck they’re ideas up.
The rhetoric in action
A good example of partnership work arose last week. When we had the beds crisis our chief executive Amanda Hume was able to call a crisis meeting with the local authority within 24 hours. So as a CCG we are very light on our feet.
We told the council that patients who are ready for discharge need to be assessed as soon as possible for social care so they are not waiting for a nursing home place. Our local authority colleagues immediately responded to that by using winter pressures money to put in three half-time social workers to do speedy assessments.
However we still have a bed crisis here with 53 patients waiting for discharge. There are some really obscure reasons for the delays but if you add them together it makes two wards’ worth. To give an example: we have somebody who is waiting to go down to their family in another part of the country and they are determined to go to one particular nursing home where at the moment there are no vacancies.
Horizontal integration
Part of our plan as a CCG is to have more contact with elected councillors so we can lobby and campaign on health issues. We already meet them via the local health scrutiny committee where they usually ask sensible and well informed questions.
At another recent meeting we talked about reablement, putting in telecare, fall monitors and GPS tracking for Alzheimer’s patients. I think the council are mindful of using things that are of proven benefit rather than running off and buying the latest thing just because the brochure looks good. They consult with us over how they spend that money - for example our Intermediate Care Centre is jointly funded by health and social care and we keep an eye on that and the spin off for them is that fewer patients need residential social care, which reduces social care costs because people can return to their own homes.
In compiling the JSNA we consulted as a CCG with the public on what they would wish us to tackle. The message was quite consistent; the public were concerned about cancer and healthy hearts, a little less concerned about smoking, very concerned about alcohol and drugs and less so about obesity - only 17% of the public were concerned about that in spite of the fact that it is one of our big problems - about 21% of Year 6 children are classified as obese, higher than the average for England. There is almost a sense of acceptance that that is what people are like and there is a strong denial that size is in any way related to what people eat and do. Its a difficult one. People will always say, It’s not what I eat, I am on my feet all day”.
This problem is not something that we are going to tackle with a health and wellbeing strategy alone, until you have some sort of fat tax you are not going to make any progress. And if a bag of salad costs more than three Melton Mowbray pork pies we haven’t got a hope of getting anywhere.
The food industry and supermarkets have a social responsibility role to play here. Locally we have not got the supermarkets on board yet and we are still reliant on national policies like food labelling. We have never gone into the area of locally influencing food retail policy but it would be nice to have pastries and things labelled not just for calories, but for things like how much exercise you would need to work off this sausage roll. If people knew that a Big Mac, large fries and a Coke was the amount of calories you would need to do the Great North Run they would be pretty shocked. It’s about putting things into a language that people understand.
We would like to have some say in licensing policy. Stopping more fast food outlets opening up is a modern analogy to John Snow taking the handle off the water pump to stop the spread of cholera - we certainly don’t want another McDonald’s for example. But these are employers and there are jobs to consider. If only salad tasted as good as a burger.
Dr Nigel Rowell is a GP and governing body member of South Tees CCG
