HC 1048-III Health CommitteeWritten evidence from British Heart Foundation (PH 78)

1. The British Heart Foundation (BHF) is the UK’s leading heart charity. Our vision is of a world where no-one dies prematurely of heart disease. Each year, heart and circulatory disease causes over 180,000 deaths, and costs the UK £30.7 billion.

2. In more than 90% of cases, the risk of a first heart attack is related to potentially modifiable risk factors, including smoking, poor diet, obesity or overweight, and insufficient physical activity.

3. We welcome the Health Select Committee’s commitment to scrutinising the impact of the health reforms on public health through this Inquiry. This submission from the BHF includes recommendations for changes to the Bill, as well as for further policy development and implementation, and draws on our responses to the Public Health White Paper.

4. Summary

History shows that public health benefits and reductions in health inequalities most frequently result from timely, evidence-based legislation. To protect population health and to create an environment that supports and enables healthy choices, individual behaviour change approaches and voluntary action by industry must be part of a much wider government strategy that includes regulation and legislation.

In particular, to protect children and young people, we are calling for plain packaging for cigarettes, for all advertisements for food and drink that is high in fat, saturated fat, sugar, and salt (HFSS food and drink) to be screened after the 9.00 pm watershed, and for the independent development of regulations for non-broadcast marketing.

While we support local community empowerment, there must be national oversight to monitor outcomes among different population groups, and to ensure action is taken where outcomes fail to improve or unacceptable variation persists.

Open access to independent national and local data on population health needs, behaviour and outcomes will be an important mechanism for enabling public scrutiny and democratic accountability, as well as effective evidence-based commissioning.

Local authorities should have clear responsibility in the Bill for protecting and improving the health of their populations, supported by Public Health England.

Public Health England must be able to provide independent advice and leadership across Government and to local commissioners and providers, and must therefore be independent of the Department of Health.

Directors of Public Health (DsPH) must have the protected independence and authority to advocate and influence across all the local authority’s policy areas and functions, and must report directly to the local authority CEO.

Public health practice must be based on evidence and robust evaluation. To support this, the Secretary of State and all health and public health structures must have a duty to promote research, and there must be effective links between commissioners, providers and academia.

The voluntary sector, patients, the public, academic institutions and clinical networks should be fully engaged and involved throughout the commissioning cycle.

The Role of National Government

5. We welcome the commitment in the White Paper to addressing the “root causes of poor health and wellbeing” and to adopting a cross-Government, life-course approach. We look forward to learning more about the mechanisms to achieve this and to enable Public Health England to work closely with other Government departments. Health Impact Assessments and Health Equity Impact Assessments should play a key role.

6. The activity and progress of local authorities in promoting health and tackling inequalities will inevitably vary. The Government should ensure outcomes are monitored, and should take responsibility for ensuring that appropriate action is taken where unacceptable variation in outcome persists. We would welcome more information about the process for making sure that this happens. This will be particularly important during the period of transition and financial challenge to ensure preventative activity does not suffer.

7. The BHF firmly believes that the provision of information, behaviour change (“nudging”), and voluntary action by industry will not on their own deliver the health outcomes to which we are all committed. Many aspects of the environment set the default options for behaviour and decision-making. The physical environment and commercial marketing, for example, can make positive health behaviours and healthy choices more difficult. In addition, while we recognise the importance of personal freedom and responsibility, this must be balanced with the need to protect population health, particularly among vulnerable groups including children who cannot be expected to take responsibility for their decisions.

8. History shows that public health benefits and reductions in health inequalities most frequently result from timely, evidence-based legislation. This is shown, for example, by legislation for safe water, clean air, seat belts, and the recent Review of smokefree laws. Upstream whole system measures are also the most cost-effective.

9. Complementary measures from different “rungs” of the Ladder of Intervention are therefore needed—rather than starting with the least intrusive measures and progressing incrementally up the Ladder as implied in the White Paper. NICE’s role should include the review of upstream national and international public health measures.

10. We were pleased to see the Tobacco Control Plan commit to the implementation of legislation to prohibit the display of tobacco at the point of sale and to prohibit cigarette vending machines—both are vital to put tobacco out of sight and reach of children. We also welcome the Government’s commitment to consult on introducing plain packaging for cigarettes. Despite health warnings, packaging remains a “silent salesman” for tobacco brands. We firmly believe that to increase the effectiveness of health warnings and address misconceptions about the risks of smoking, legislation is needed to introduce plain packaging for cigarettes across the UK.

11. Legislation and regulation is also needed to protect children and young people from the harm caused by the marketing of HFSS food and drink. Although the advertising of these products is prohibited during children’s programming, a recent review by Ofcomshowed that just over half of children’s viewing time is in commercial adult airtime. To protect children and young people, we are calling for all advertisements for HFSS foods and drinks to be screened after the 9.00 pm watershed, and for the independent development of regulations for non-broadcast marketing (including online, in print and on product packaging).

Public Health England

12. Public Health England has great potential to tackle the wide range of social determinants of ill health and health inequalities and to drive improvement across all national and local policy areas and functions. But to achieve this Public Health England must be able to provide independent advice and leadership, and must be independent of the Department of Health.

Directors of Public Health in Local Authorities

13. Transferring public health functions into local authorities also has great potential to promote collaborative action to tackle the wide social determinants of health. Local authorities should have clear responsibility for protecting and improving the health of their populations, supported by Public Health England.

14. The transition to local authorities must be carefully managed to ensure that specialist public health expertise and experience is not lost. There must be a coordinated approach to workforce training and supply that considers not just Directors of Public Health (DsPH) but those who work in jobs that have a bearing on health (such as planning and transport).

15. DsPH should work to implement NICE public health guidance, including guidance on the prevention of cardiovascular disease, prevention of overweight and obesity, and on physical activity and the environment.

16. DsPH will need the protected independence, authority, and resources to drive health improvement across all local government policy areas and functions. To achieve this, they must be directly accountable to the CEO (employed by local authorities with an honorary contract with Public Health England).


17. There must be a clear, publicly accessible audit trail leading from population Joint Strategic Needs Assessment (JSNA), through to service design, service implementation, monitoring and review. The effectiveness of this process will depend on close partnership working and data-sharing between DsPH and GP commissioning consortia.

18. We would like to see guidance on the benefits of supra-local commissioning by local authorities. This is a valuable way of providing interventions for small and scattered populations that are not defined geographically, as well as a way of pooling resources for larger populations and avoiding duplication.

19. During this period of significant organisational change, the voluntary sector and academic institutions remain a constant and lasting source of expertise and evidence. As activity is increasingly devolved to a local level, national voluntary organisations also play an important role in identifying and disseminating local good practice, and exploring the needs of population groups across organisational boundaries.

20. Although the BHF does not supply services under contract to the NHS or local authorities, we are a significant contributor to the health and well-being of local populations. We have invested £9 million in our Hearty Lives programme which aims to reduce high levels of cardiovascular disease (CVD) in deprived communities. Strategic health authorities, primary care trusts and local authorities will need to work closely with voluntary sector organisations to see co-investments, such as the BHF investment in Hearty Lives, safely through the transitional period.

21. Charities, patients, the public and academic institutions should be fully engaged and involved throughout the commissioning cycle. At a local level this should start with involvement in the development of the local Joint Strategic Needs Assessments, and Health and Wellbeing Boards should be responsible for ensuring that this happens.

22. National and local commissioning policy and guidance should also take better account of the role of national charities as co-commissioners. This policy and guidance should distinguish appropriately between funding from general taxation and charitable funding to ensure the latter is not subject to inappropriate bureaucratic processes which impede the speed and flexibility of response for which the voluntary sector is so valued.

23. The new public health commissioning architecture is very complex—to facilitate the engagement of the voluntary sector, we urge the Government to ensure that the different commissioning routes and opportunities for engagement are clearly communicated.

24. Cardiac and stroke networks should also be fully engaged throughout the commissioning cycle. Clinical networks play a vital role in supporting and coordinating an integrated pathway across both prevention and care, and in ensuring services are planned, and resources are allocated from the perspective of the whole system rather than piecemeal.

Funding Public Health Services

25. While we welcome the commitment to a ring-fenced budget, the scope of this budget needs clarification. The actual amount allocated to local authorities must be sufficient to enable DsPH to drive health improvement, and activities currently funded from NHS funds must not be simply re-badged as “public health”.

26. We have concerns that the Health Premium—which financially rewards areas that appear to be performing well—may penalise communities where need is growing fastest, thereby widening health inequalities. In addition, there can be a significant time lag between a public health intervention and its measurable outcomes, and some of the economic and environmental factors that influence health inequalities are outside the control of local authorities.

Public Health Research and Data

27. We welcome the recognition in the White Paper that “Public health evaluation and research will be critical in enabling public health practice to develop into the future and address key challenges and opportunities”.

28. Medical research is key to preventing heart disease. The UK is a world leader in cardiovascular research. But to maintain this status, research must be valued and embedded as a core function at all levels of the new NHS landscape. To achieve this, we are calling for the promotion of research to be a direct duty on the Secretary of State, and on all health and public health structures, including Public Health England and commissioning consortia.

29. There is currently a gap between public health research and the provision of public health services. Effective links will be needed between commissioners, providers, the National Institute for Health Research (NIHR) and academia, to ensure public health research can be coordinated across local structures and that public health practice is based on evidence and evaluation.

30. Public health knowledge management systems are also crucial to ensure evidence-based practice. The roles of information officers should be protected, maintained and developed. Frameworks and guidance on the evaluation of “what works” should also be developed and disseminated.

31. Open access to independent and usefully analysed and presented data on population health needs, outcomes and behaviour is an important mechanism for enabling public scrutiny, and enabling commissioners and charities like the BHF to invest resources most effectively. This should include the Public Health Outcomes Framework, and national lifestyle surveys. We welcome the proposal to produce an update of the Local Tobacco Profiles. However, clarity is needed about the future of the valuable data collection and analysis functions currently performed by the Public Health Observatories.

32. Data must be collected in a way that allows variations in outcomes to be compared between different population groups (including socio-economic, geographical, gender, and ethnic background) - focusing only on averages can hide persistent or worsening inequalities.

The Public Health Outcomes Framework

33. We welcome the Government’s focus on public health outcomes. However, it is important that process measures that tell us whether we are on track to achieve those outcomes are also maintained at a national and local level as some outcomes may not be identifiable until many years after an intervention.

34. We are also concerned that limiting the indicators to those with short time lags for data and those that are meaningful at a local level, as proposed in the consultation on the Outcomes Framework, may exclude valuable indicators for chronic disease prevention. Indicators on second-hand smoke exposure among children for example, may be most meaningful at a national or sub-national level.

35. We welcome the inclusion of indicators covering a wide range of determinants of health, and believe that this breadth should be maintained. As heart disease is the single biggest killer in the UK, indicators on the prevalence of cardiovascular disease and risk factors for cardiovascular disease must be included. The “national ambitions” in the Tobacco Plan and other forthcoming plans should also be included in the Framework.

Forthcoming Public Health Plans and Policy

36. We look forward to learning more about the strategies for tackling particular public health challenges. Clear visions for social marketing, for promoting physical activity, and for tackling obesity are needed and we hope to see this detail provided in national plans.

Obesity and physical activity

37. We strongly agree with the White Paper that active travel and physical activity must become the norm in communities. We now hope to see more detail on how this will be achieved. Access to local parks and safe outside space and a reduction in the speed limit to 20 miles per hour in residential areas are key to enabling people to build physical activity into their daily lives.

38. Information about the nutritional content of food is also crucial to create an environment that enables consumers to make healthy choices. Research has shown that front of pack (FOP) labels including traffic light colours, the words “high”, “medium” and “low”, and percentage guideline daily amounts help consumers tell at-a-glance what’s in the food they’re buying.

39. Developments concerning food labelling at European Union level will allow continued use of additional forms of expressions (AFEs) already in the marketplace. We are calling on the UK Government to support AFEs and FOP labelling which include information on energy, fat, saturated fat, sugar and salt. The Government should strongly support and encourage the use of the Food Standards Agency’s Multiple Traffic Light FOP labelling system within the UK. Those companies choosing to use their own labelling schemes should provide independent and transparent evidence to demonstrate that these are effective.

40. We are pleased that work is underway on the provision of nutritional information at the point where decisions are made in cafes and restaurants, and hope to see this extended to give consumers more comprehensive information about the nutritional content of foods rather than just the energy content.

41. To eliminate industrial trans fats, action will be needed across small and medium-sized catering businesses, as well as large suppliers, manufacturers and providers. If voluntary action is unsuccessful, the Government must take legislative action to remove trans fats. Additional work is also urgently needed to substantially reduce saturated fat consumption and replace with unsaturated fats.

42. We understand that the Responsibility Deal targets for salt reduction are equivalent to the FSA 2012 targets. However, further ongoing action by manufacturers, retailers and caterers will be essential to reduce salt consumption to recommended levels.

43. A key aspect of a life-course approach to public health should be the promotion of healthy eating and physical activity from a young age including during the early years and at school. The White Paper gives helpful indications of what “good schools” will do to promote health, but monitoring must be in place to identify schools that are not meeting expectations and these should be offered high quality, evidence-based support and guidance.

44. We understand that there will cease to be a nationally recognised Healthy School Status and urge the Government to ensure that the necessary infrastructure and support is made available so schools can protect the health of children and young people.

Social marketing

45. We look forward to reading more in the forthcoming Social Marketing Plan about how healthy diets, physical activity, smoking cessation and smoke-free homes and cars will be promoted. The Plan must give particular consideration to the need for dedicated interventions for groups that suffer disproportionately from cardiovascular disease, including some black and minority ethnic groups.

Congenital and inherited heart conditions

46. Throughout the White Paper consultations, there is an absence of reference to inherited cardiac conditions, such as familial hypercholesterolaemia (FH) which causes high blood cholesterol levels and a greatly heightened risk of heart disease. NICE has recommended the implementation of cascade screening whereby first degree relatives of known FH sufferers are screened for the genetic defect and managed appropriately if found to be affected.

47. There is also a lack of reference to congenital heart disease, despite this being the most commonly occurring major congenital abnormality affecting one in every 145 babies. Effective routine screening ante-natally and post-partum is crucial, and audit and specialist professional training are needed to support this.

48. The BHF would welcome the opportunity to provide additional information on any of the points in this submission.

June 2011

Prepared 28th November 2011