APPENDIX 37
Memorandum by National Heart Forum (PH
71)
1. INTRODUCTION
1.1 The National Heart Forum (NHF) welcomes
the opportunity to submit written evidence to the select committee
on this very important inquiry into public health.
2. THE NATIONAL
HEART FORUM
2.1 The NHF is the leading alliance of over
40 organisations working to reduce the risk of coronary heart
disease (CHD) in the UK. Member organisations represent the medical
and health services, professional bodies, consumer groups and
voluntary organisations. Members also include many individual
experts in cardiovascular research. Government departments have
observer status. The purpose of the NHF is to work with and through
its members to reduce disability and death from CHD. Our four
main objectives are:
— to provide a forum for members for
the exchange of information, ideas and initiatives on coronary
heart disease prevention;
— to identify and address areas of
consensus and controversy;
— to develop policy based on evidence
and on the views of member organisations;
— to stimulate and promote effective
action.
2.3 The NHF embraces professional, scientific
and policy opinion in current issues in CHD prevention. It coordinates
action to reduce heart disease risk through information, education,
research, policy development and advocacy.
2.4 Given the expertise and multidisciplinary
background of our membership and the impact our members have on
the wide sphere of public health the NHF is uniquely placed to
offer scientific advice and put forward policy recommendations
on public health policy.
3. CORONARY HEART
DISEASE AND
PUBLIC HEALTH
3.1 Coronary heart disease is the UK's biggest
killer. It is the leading single cause of death of over 140,000
people per year, of whom nearly 20,000 die before they reach the
age of 65. It causes illness and disability for many more: each
year an estimated 300,000 people have a heart attack, while a
further 1.4 million suffer from angina (chest pain).
3.2 Yet CHD is largely preventable by tackling
the main risk factors of poor diet, smoking, and physical inactivity.
Public health policies which focus on helping people make lifestyle
changes and hence reduce their CHD risk factors will have a significant
impact on the reduction of heart disease rates. If current knowledge
about the causes and prevention of coronary heart disease is turned
into effective public health policy action, mortality and morbidity
rates could be substantially reduced within a matter of decades.
3.3 The NHF warmly welcomes the Government's
recent proposals for action on the prevention of coronary heart
disease set out in the White Paper Saving Lives, the National
Service Framework for Coronary Heart Disease and the recently
published NHS Plan. We urge that these policies and initiatives
are comprehensively supported and sustained across Government—taking
into consideration issues such as nutrition, tobacco control,
physical activity, education, agricultural, transport and social
policy, which all impact on the nation's heart health.
3.4 Up until now efforts to address many
of the risk factors and determinants of CHD have been piecemeal
and only partially successful. The Government's recent prioritisation
of, and commitment to tackle, heart disease is highly commendable
and offers a real chance to eradicate preventable heart disease
in the UK. But policy makers must be encouraged to fulfil their
commitment to tackle CHD by implementing coherent and comprehensive
strategies which tackle the known risk factors across the whole
population. The risk of not implementing and sustaining a coherent
policy will be huge and costly increases in the number of patients
in coronary care wards in the coming decades. Currently, over
2 million people suffer from illness and disability through coronary
heart disease each year. The estimated cost to the British economy
in lost production and healthcare costs is £10 billion every
year. This is likely to rise rapidly with the ageing population.
3.5 There is an urgent need for significant
investment in public health and disease prevention strategies.
The government is aware of this—as reflected in the NHS
Plan and the Secretary of State's call to bring public health
"out of the ghetto" (LSE Health Annual Lecture, 8 March
2000). But many of the public health proposals put forward by
the government are dependent on evidence of effectiveness, which
is not yet available. However, the evidence is already compelling
and justifies action now (see below).
3.6 The NHF in collaboration with the Cancer
and Public Health Unit and Health Promotion Research Unit of the
London School of Hygiene and Tropical Medicine prepared a report
for the Chief Medical Officer: Monitoring the progress on the
2010 target for coronary heart disease mortality: Estimated consequences
on CHD incidence and mortality from changing prevalence of risk
factors. This report's conclusions clearly show that effective
public health action on the primary risk factors could have a
significant impact on reducing CHD rates.
3.6.1 Contribution of major risk factors to
CHD
The principal risk factors for coronary heart
disease are low levels of physical activity, obesity, raised blood
cholesterol, raised blood pressure, and smoking.
Simple risk factor changes, related to lifestyle,
could have major consequences on CHD. A study in Finland between
1972 to 1992 estimated that three-quarters of the decline in ischaemic
heart disease (IHD) deaths over this period were due to declines
in blood cholesterol, blood pressure and smoking.[77]
Changes in the risk factors for CHD could significantly
reduce the incidence of CHD. There is evidence that existing interventions
to encourage people to modify their lifestyle are effective. However,
there is room for improvement and more systematic research is
clearly needed.
Diet
Poor diet can lead to raised blood cholesterol,
high blood pressure levels and obesity. A diet rich in fruit and
vegetables has been shown to have a protective effect. [78]
Wealthier individuals eat more fresh fruit and vegetables. [79]
Obesity is more common in manual than non-manual groups, especially
in women.
Physical activity
Low levels of physical activity can increase
the risk of coronary heart disease through obesity, stress, raised
blood pressure etc. It is estimated that approximately 36 per
cent of male CHD deaths and 38 per cent of female CHD deaths are
associated with inadequate physical activity[80]
to confer any cardiovascular benefits.
If each individual were to move up one exercise
level (National Fitness Survey) ie from sedentary to light exercise
such as walking, this would reduce deaths from CHD among men and
women by 14 per cent.
Obesity[81]
Being overweight or obese is linked with several
known CHD risk factors. The prevalence of high blood pressure
and diabetes is three times higher among overweight people than
among those of normal body weight, and obesity is also associated
with higher levels of total blood cholesterol. [82]
It is estimated that 5 per cent of male and 6 per cent of female
CHD deaths are attributable to obesity.
Cholesterol
It is estimated that approximately 45 per cent
of all CHD deaths among men are attributable to raised blood cholesterol
levels, [83]
and 47 per cent of all female CHD deaths.
Lowering average blood cholesterol levels alone
could achieve the Government's target of a 40 per cent reduction
in CHD deaths.
Smoking
If smoking in the UK continues to decline at
rates reported over the last twenty years, current Government
targets will be comfortably exceeded by 2010.
The largest benefits are to be found in the
lower social classes, for example a 9 per cent reduction in CHD
deaths among those in social class V could be achieved if all
smokers stopped smoking. This could contribute to a narrowing
of the health gap.
Blood pressure
It is estimated that approximately 15 per cent
of all male CHD deaths and 12 per cent of all female CHD deaths
are attributable to having high blood pressure. [84]
3.7 This research shows the large extent
to which the major risk factors contribute to CHD rates. It can
be concluded from this research that the current best investment
in prevention is in the area of diet/nutrition and physical activity.
Tackling these risk factors will address other risk factors and
diseases like obesity and diabetes.
3.8 Given the prevalence of CHD and the
cost of treatment, options for coping with demands on the NHS
need to be explored. The National Service Framework for CHD goes
some way in addressing this. But in order to reduce demand and
to really gain an optimal return for investment in the health
service, investment must be made in prevention by tackling the
risk factors and therefore reducing avoidable demand.
3.9 A comprehensive approach encompassing
all risk factors is essential to maximise a return on investment.
Up until recently investment has largely been centred on one major
risk factor: smoking. It is crucial that investment is now made
in tackling other risk factors starting with diet/nutrition and
physical activity, to which the government has committed itself
in the White Paper, Saving Lives and the new NHS Plan.
4. INTERNATIONAL
MODELS
4.1 The NHF also works across Europe with
similar organisations within the European Union. The NHF strongly
recommends that the Committee undertake international comparisons
of public health systems in other countries, for example Sweden,
Finland or Canada. We also recommend that the Committee take into
consideration the current EU proposals for a European Community
public health framework strategy and action programme.
5. INTER-OPERATION
OF HEALTH
ACTION ZONES,
EMPLOYMENT ACTION
ZONES, HEALTHY
LIVING CENTRES,
EDUCATION ACTION
ZONES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
PLANS
5.1 The Committee should also look at the
integration of other nationwide local initiatives including Sports
Action Zones, Neighbourhood Renewal areas, Sure Start and Sure
Start Plus.
5.2 The NHF commends these local initiatives
but is concerned that there is often a lack of co-ordination between
the groups, on both national and local level, and that overlap
and duplication may be wasteful of time and resources. Many of
these groups are not nationwide and therefore only benefit some
communities, which can lead to further or other inequalities.
The benefits to public health from the different initiatives are
clear, but the benefits afforded may be eroded through a lack
of co-ordinated action.
5.3 The NHF recommends that these local
groups/initiatives should be merged and coordinated centrally
and at local level to ensure synergy, leadership and minimal overlap.
The groups could be extended, as indicated in the NHS Plan, to
include primary care groups (PCGs) and primary care trusts (PCTs),
although it is not clear how this would work. The Local Strategic
Partnerships (LSP), proposed in the Neighbourhood Renewal Strategy,
would be an ideal forum to bring these groups together.
5.4 More "upstream" policies,
such as welfare payment policies, are needed which will have a
wide range of consequences, including benefits to health, rather
than "downstream" policies which are specifically targeted
on health. Multidisciplinary groups like LSPs would offer the
opportunity for more co-ordinated upstream policies.
5.5 There is confusion surrounding the roles
of professionals and organisations involved in public health at
local level. It seems to stem from whether the responsibility
for public health is joint or unique: public health professionals
feel that they should oversee public health initiatives, while
the participation of other health professionals, for example clinicians
and health visitors, is governed by a laissez-faire rhetoric.
There is no statutory obligation for joint working between health
professionals or others working in this sector, nor is there any
accountability for joint working. What is needed is not structural
change but a clear definition of roles and responsibilities so
there can be no abdication of accountability, and to ensure local
level leadership. An absence of clear accountability and responsibility
has led to competition between public health professionals and
a failure to join up local initiatives.
5.6 The problem is compounded by the government's
"initiative overload". One way of assisting in joining
up would be through integrating community plans with health impact
programmes (HImPs) and regeneration plans under LSPs and by implementing
joint performance management systems and the pooling of resources
as appropriate.
5.7 joined up local working will be assisted
further with unified, or pooled, budgets managed jointly by local
authorities and health authorities.
6. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
6.1 The NHF welcomes the establishment of
the Health Development Agency (HDA); it has been given a laudable
task. The NHF is concerned that the HDA's budget of £10 million
is not sufficient to carry out the aims and objectives it has
been set in Saving Lives. In order to carry this out effectively
it is estimated that further funding in the region of an extra
£10 million would be necessary. The HDA is not just a "NICE
for public health"—it should also be properly resourced
to provide training and development services to improve the quality
of public health practice and undertake independent reviews of
public health for Government and others.
6.2 It is now generally recognised that
influences in all sectors of society affect health, however in
practice most efforts to improve health are focused in the health
sector. The HDA is ideally placed to examine wider public policy
affecting health and to influence upstream policies. This could
best be done through cross-departmental commitment which could
be legitimised through funding from other government departments
and which would enable cross government involvement in HDA priority
setting and planning.
7. PUBLIC HEALTH
AT GOVERNMENT
LEVEL
7.1 Public health should be a responsibility
in all government departments—at ministerial and senior
civil service level.
7.2 Modernisation of government is about
working across boundaries. Public health can only be delivered
by working across government. Therefore public health should be
integral to the Government modernisation efforts. The Chief Medical
Officer and his colleagues have always had a role in all government
departments. However, this should be strengthened and developed
further. Indeed the CMO's role in public health policy is pivotal
and the NHF looks forward to seeing the long awaited review of
public health commenced by the previous CMO two years ago.
7.3 An alternative model for public health
at government level would be to extend its influence to the Cabinet
Office, which could have a special role in health impact assessment
across government, supported by the Department of Health. This
model could assist in effectively implementing public health across
Government and would be in line with the Government's modernisation
plans. The investment for such a restructure could be through
the modernisation funds.
8. PUBLIC HEALTH
AT REGIONAL
LEVEL
8.1 There is a real need for joined up working
between regional government, regional offices of the NHS, the
regional development agencies and the regional assemblies. This
should be facilitated by regional development plans. Effective
public health action plans need multi-agency unity at all levels
but particularly at the regional level. A commitment to this from
key players within these organisations must be sought. This sentiment
was muted in the NHS Plan, but needs to be developed further.
8.2 Local Authorities
LAs and HAs should share ownership of public
health. Up until now public health has largely been seen as being
the responsibility of the Department of Health and health authorities.
Although HAs are appropriate bodies to oversee public health delivery,
it is the LAs who have governance over many health determinants
and health impact services, and they also have more expertise
and experience than health authorities in consulting locally and
working in partnership.
8.3 Primary Care Trusts and Primary Care
Groups (PCTs and PCGs).
Public health professionals and health promotion
professionals should sit on the executive boards of PCGs and PCTs
in order to assist in strategic planning. Public health is often
marginalised and little or no importance is attached to the delivery
of public health or its place in programme management. Although
this is part of the annual performance review it has largely been
ignored and is often not taken seriously.
9. PRIORITIES
IN PUBLIC
HEALTH
9.1 Recently, public health priorities have
focused on adults, because they have been disease focused. But,
because many of the determinants of health in later life start
in childhood there should be a sharper focus on the health of
children and young people. The Government has prioritised children
in many of its policies across government, through education,
welfare, tax credits and education, but to a large extent these
initiatives have not been "joined up". The Government
does not seem to acknowledge the impact these policies have on
the health of the young. The Government needs to focus on what
it can do for children's health and must show its commitment to
children through a strategic cross government commitment to public
health. The Government has gone some way in addressing this with
the announcement of the £450 million Children's Fund and
by prioritising children in the NHS Plan. The NHF is keen that
this focus on children is strategically and comprehensively implemented
across government.
10. PUBLIC HEALTH
POLICY AND
HEALTH INEQUALITIES
10.1 Our Healthier Nation, and more specifically
Saving Lives and Reducing Health Inequalities: An action report,
published by the Government last year, proposed many laudable
cross Government policies and initiatives which could have significant
impact on reducing health inequalities. However it is still too
early to know whether they have been effective as some of these
policies are still in development, and others have only recently
been implemented. However, the NHF is concerned that these very
important and influential initiatives will be superseded by those
proposals put forward in the new NHS Plan, which we hope will
complement, rather than overwrite Our Healthier Nation.
11. HEALTH IMPACT
ASSESSMENT (HIA)
11.1 There is a requirement in the Amsterdam
Treaty that all policies and legislation should be monitored for
health impact. The NHF looks forward to seeing this implemented
for both national and EU policies. We believe that health impact
assessment should also assess the potential to reduce and not
widen health and social inequalities—which have such a great
bearing on health—and will help monitor reductions in health
inequalities. HIA needs to be undertaken or validated by independent
agencies (for public and professional credibility), it must be
transparent and in the public domain. Agencies like the Health
Development Agency and the Food Standards Agency, or universities
and research centres, could carry out HIA. The Department of Health
should work more closely with other impact assessment groups,
like those located in the Cabinet Office.
October 2000
1. EXECUTIVE
SUMMARY AND
RECOMMENDATIONS
1.1 Coronary heart disease and public health
(a) Coronary heart disease (CHD) is the UK's
biggest killer. It is the leading single cause of death of over
140,000 people per year, of whom nearly 20,000 die before they
reach the age of 65.
(b) Public health policies which focus on
helping people make lifestyle changes and hence reduce their CHD
risk factors will have a significant impact on the reduction of
heart disease.
(c ) Policy makers must be encouraged to
fulfil their commitment to tackle CHD by implementing coherent
and comprehensive strategies which tackle the known risk factors
across the whole population.
(d) In order to reduce demand and to really
gain an optimal return for investment in the health service, investment
must be made in prevention by tackling the risk factors and therefore
reducing avoidable demand. The current best investment in prevention
is in the area of diet/nutrition and physical activity.
1.2 International models
The NHF strongly recommends that the Committee
undertake international comparisons of public health systems in
other countries, for example Sweden, Finland or Canada. We also
recommend that the Committee take into consideration the current
European Commission proposals for a European Community public
health framework strategy and action programme.
1.3 Local level
(a) The Committee should look at the integration
of other nationwide local initiatives including Sports Action
Zones, Neighbourhood Renewal areas, Sure Start, Sure Start Plus.
(b) All these local group/initiatives should
be merged and co-ordinated centrally at local level to ensure
synergy, leadership and minimal overlap. The groups could be extended,
as indicated in the NHS Plan, to include PCGs and PCTs.
(c ) More "upstream" policies are
needed which will have a wide range of consequences, rather than
"downstream" policies which are specifically targeted
on health such as specific disease targets.
(d) A clear definition of roles and responsibilities
of professionals and organisations is needed so there can be no
abdication of accountability, and to ensure local level leadership.
(e) "Joining up" could be assisted
by integrating community plans with HImPs and regeneration plans
under Local Strategic Partnerships (LSPs) and by implementing
joint performance management systems and the pooling of resources
as appropriate.
1.4 Health Development Agency
(a) The NHF is concerned that the HDAs budget
of £10 million is not sufficient to carry out the aims and
objectives it has been set in Saving Lives. The HDA should also
be properly resourced to provide training and development services
to improve the quality of public health practice and undertake
independent reviews of public health for Government and others.
(b) The HDA is ideally placed to examine
wider public policy affecting health and to influence upstream
policies. This could best be done through cross departmental commitment
which could be legitimised through funding from other government
departments.
1.5 Central government
(a) Public health should be a responsibility
in all government departments—at ministerial and senior
civil service level.
(b) The Chief Medical Officer and his colleagues
have always had a role in all government departments, this should
be strengthened and developed further.
(c ) Public health could be extended to the
Cabinet Office, which could have a special role in health impact
assessment across government,, with the support of the Department
of Health. This could also assist in effectively implementing
public health across government.
1.6 Regional level
(a) There is a real need for joined up working
between regional government, regional offices of the NHS, the
regional development agencies and the regional assemblies. This
should be facilitated by regional development plans.
(b) LAs and HAs should share ownership of
public health.
(c ) Public health professionals and health
promotion professionals should sit on the executive boards of
PCGs and PCTs in order to assist in strategic planning.
1.7 Priorities in public health
(a) Many of the determinants of health in
later life start in childhood, therefore there should be a sharper
focus on children and young people in health policy. The NHF are
keen that this focus on children is strategically and comprehensively
implemented across government.
(b) The NHF are concerned that the very important
and influential initiatives put forward in Our Healthier Nation
will be superseded by the new NHS Plan.
1.8 Health impact assessment
The NHF considers that health impact assessment
should also assess the potential to reduce and not widen health
and social inequalities.
National Heart Forum
October 2000
77 Vartiainen, E, Puska, P, Pekkanen, J, Tuomilehto,
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in mortality from ischaemic heart disease in Finland. British
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78
Ness, A R and Powles, J W (1997). Fruit and vegetables, and cardiovascular
disease: a review. International Journal of Epidemiology, 26,
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79
British Heart Foundation (1999) Coronary heart disease statistics.
1999 edition. Back
80
Vigorous exercise (12+ occasions of 20 minutes vigorous activity
in past 4 weeks). Back
81
Body Mass Index (BMI) greater than or equal to 30. Back
82
Brownson, R C, Remington, P L, Davis, J R (1993). Chronic Disease
Epidemiology and Control. American Public Health Association.
Port City Press, Baltimore. Back
83
Cholesterol levels over 6.5mmol/l. Back
84
Diastolic blood pressure above 76 mm Hg. Back
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