4 Public health in practice
Tackling the causes of the causes
of poor health
82. We have described the new arrangements for
the promotion of health and wellbeing and for the integration
of health, public health and social care. We have also examined
the means by which local government and its partners in local
and national health, in the community sector and among providers
might assess residents' needs and create strategies to deal with
them. These organisational matters will be important, but the
approach that councils and their local health partners take to
public health will be critical. It will not be enough for one
"public health" department in isolation to commission
services to deal with single issues such as obesity or smoking.
Councils will need to focus all their policies and services on
the social determinants of health—the social, economic and
environmental reasons why people experience ill health or develop
unhealthy behaviour—if they are to make an identifiable
difference to the health and wellbeing of their residents. In
this chapter we consider what this should mean in practice and
how the impact of their work might be measured.
83. Neil Blackshaw, of Easton Planning, a consultancy
with major public sector clients, explained, "The English
health system has been dominated by the medical model of health
throughout the evolution of the NHS."[184]
In contrast,
the [social determinants of health] model states
that a person's health status is a function of their social, economic
and environmental situation […] The failure to espouse this
model wholeheartedly was the result of a combination of silo working
and professional resistance and it has contributed to the persistence
in inequities.[185]
84. Dr Nicholas Hicks, Director of Public Health
in Milton Keynes, was concerned that despite public health functions
moving over to local government, some local authorities might
not recognise the way in which those functions could then be integrated
with the council's existing responsibilities and services:
There is still a risk that too many people see public
health as just preventive services, health improvement or health
protection and do not necessarily see the whole strategic content
[…] does the council really get its role as being the leader
and responsible body for health in its community?[186]
Dr Mike Grady, principal adviser at the UCL Institute
for Health Equity, agreed and raised the issue of resources:
early years education, our young people who are unemployed
and not in training, our people who need support […] and
our older people […] that kind of spend needs to shift into
a public health agenda rather than provision (of specific public
health services).[187]
He wanted to see an approach that went beyond "just
… commissioning" to one about empowering communities
and creating greater social cohesion. He said that "the primary
driver needs to be the empowerment of individuals and communities,
and then a range of support services and commissioned services
support that activity."[188]
We saw on our visit to Kent an example of integrated services
in Gravesend town centre at the Gr@nd Healthy Living Centre, which
incorporated services such as smoking cessation, a job club and
youth counselling. We heard that such integration, currently taking
place at one community centre, would need to be expanded by a
local authority throughout its area and across its services. Sheffield
City Council described this as the "place-shaping capacity
of councils",[189]
and David Buck, from the King's Fund, told us that
the Marmot review has been working quite hard with
lots of local areas to try to embed its overall high-level policy-type
advice in to what this can mean locally. I know the LGA is also
working on this agenda […] One of the critical roles is to
make this meaningful for local decision makers.[190]
Professor Chris Bentley, an independent population
health consultant, referred to this approach, which he described
as a "whole system approach", in relation to alcohol-related
harm, telling us that it might include:
Population level inputs: licensing; bylaws on street
drinking; controls on advertising; enforcement of trading standards/sales
to minors;
Community level inputs: extended school education
programmes; health trainers; community lifestyle initiatives;
health champions
Service level inputs: Tier 1 - 4 alcohol services;
social care wraparound services (debt management; housing support;
job support).[191]
Dr Grady was confident that local government was
"grabbing hold of this agenda", and was not "being
dragged back … into lifestyle initiatives"—commissioning,
for example, one education campaign to tackle one health issue,
such as smoking. He said such initiatives "do not work and
certainly do not work in the bottom 50% of the social gradient
of health".[192]
Examples of local authority initiatives
85. Witnesses gave us examples of how they hoped
to use such an approach to begin to shape the conditions in which
people live. On the example of dealing with alcohol-related harm,
Newcastle City Council said that
instead of simply looking at alcohol treatment services,
which is dealing with the problem too late, we are looking at
the environment in which people think about and consume alcohol.
That includes looking at the availability of it through not just
pubs and clubs but also off-licences.[193]
On another health issue, obesity, Sheffield City
Council explained that
we also want to look at some of our by-laws to see
what we can do in terms of where food outlets are placed: are
they near schools? Do we want some food outlets, takeaways and
so on, in certain places?[194]
86. Decisions on appeal by Planning Inspectors
have shown that in order successfully to refuse planning permission
for a takeaway on the grounds of proximity to a school and the
existence of a school's healthy eating policy, a local authority
must also point to an over-concentration of takeaways in a certain
area and to evidence of a link between childhood obesity and their
proximity to schools.[195]
Several councils, such as St Helen's, have now published supplementary
planning guidance relating to takeaway establishments, putting
in place a clear policy to exclude them from a certain distance
around schools.[196]
87. In early January 2013, Westminster City Council
and the Local Government Information Unit, in a joint report on
the role of councils in public health, proposed several ways in
which local authorities might embed healthy behaviour in their
communities. One suggestion involved a link with welfare:
Relocalisation of council tax benefit [...] combined
with new technologies provide an opportunity for councils to embed
financial incentives for behaviours that promote public health.
The increasing use of smart cards for access to leisure facilities,
for instance, provides councils with a significant amount of data
on usage patterns. Where an exercise package is prescribed to
a resident, housing and council tax benefit payments could be
varied to reward or incentivise residents.[197]
BMA member and GP Dr Lawrence Buckman called the
idea "draconian and silly": "The best way [councils]
can intervene is to stop restaurants and fast-food chains providing
the kind of food that make people put on weight, and interfere
with the way foods are sold in shops."[198]
The Westminster City Council and LGIU report, however, did include
the proposal:
In areas identified as food deserts, where fresh
and affordable foods needed to maintain a healthy diet are unavailable,
councils could offer incentives to local shops that make such
services available through social investment funds.[199]
When we asked Professor Chris Bentley for his assessment
of the idea, he told us, "if they [Westminster City Council]
are saying, 'We have a range of other things we can do to support
you to get yourself in a position where you can benefit from these
interventions,' I think that is perfectly sensible."[200]
He also suggested, in order to change behaviour across a community,
some councils might benefit from more advice: "While central
direction is not an option, there is a strong case for better
guidance and developmental support on what will be needed to achieve
population level change".[201]
When we put this point to the Health Minister, Anna Soubry MP,
she cited smoking and how local authorities, "under the guidance
of PHE, who can provide statistics, advice" etc, could identify
a local ward's incidence of smoking and then make a local decision
to target smoking. In this way, she said, local councils could
then "apply an order to make children's playgrounds no smoking
areas […] work with the local school […] and […]
make sure that all the pharmacies have got the right gear, that
the GPs are stuck in on it and so on".[202]
88. Local authorities, if they
are to grasp fully the opportunity afforded to them by the return
of public health, will need to look beyond those services traditionally
considered to be "public health", such as health protection,
health promotion and disease prevention, and tackle the causes
of the causes of poor health, working with local partners and
using all the powers, personnel and services at their disposal.
The evidence we received makes it clear that people, particularly
in vulnerable groups, are more likely to exhibit a range of unhealthy
behaviours. Single initiatives targeting individual lifestyle
choices, such as drinking or smoking, have been shown not to work,
especially among people at the lower end of the social gradient
of health. Authorities should be willing to take one step back
from treatment to look additionally at by-laws, education campaigns
and how to involve, for example, GPs, pharmacies or debt management
and housing services in a more holistic attempt to deal with the
multiple reasons behind complex health problems.
EARLY YEARS
89. Sir Michael Marmot, in his review of health
inequalities in England, stated, "efforts to reduce health
inequalities […] must address […] the quality of early
years experiences."[203]
The review also noted:
What a child experiences during the early years lays
down a foundation for the whole of their life. A child's physical,
social, and cognitive development during the early years strongly
influences their school-readiness and educational attainment,
economic participation and health.[204]
Professor Chris Bentley, agreed, "The key one
is about early start, because if you miss children in the first
five years of life, when their cognitive abilities are developing,
it means they are playing catch-up for the rest of their lives."
[205] He was,
however, concerned that "Health and Wellbeing Boards seem
to be neglecting that."[206]
Other witnesses indicated that HWBs were concentrating
on early years interventions. Liam Hughes, the independent Chair
of Oldham Shadow HWB, said he would like to "focus on the
emotional wellbeing of very young children and also on early speech
and language." He added that over "a period of a few
years we should be able to see those children more ready for school
at age four and a half or five." [207]
Dr Mike Grady also pointed out that readiness for school could
be measured:
If you look at the figures for Birmingham City Council
in relation to readiness for school, what you will find is within
three years they shifted that figure from 38% to 55% by having
a coherent strategy, agreed joint priorities, integration of services
and an absolute focus on what the health outcome was that they
wanted to achieve.[208]
Cllr Mary Lea of Sheffield City Council said: "We
think it is really important to focus on early life, nought to
three, that age group. That is absolutely vital".[209]
90. Local authorities will of
course wish to base their public health work on their Joint Strategic
Needs Assessments, but we note how several councils have placed
early years interventions—literacy, readiness for school
and childhood obesity programmes—high on their list of priorities.
We commend authorities to bear this in mind when making their
decisions, given the importance of early years development in
people's later health and wellbeing.
EMPLOYMENT
91. The connection between work and health was
emphasised by Westminster City Council, when it told us of the
employment initiatives that it would seek to introduce:
Employment is one of the most evidence based determinants
to a person's health and well-being […]. Our Health and Wellbeing
Strategy will help people to successfully return to work and retain
work by supporting people with health conditions/disabilities
and promoting quality work and health and well-being in the workplace.[210]
Such evidence might include a study of increased
life expectancy in local authority areas between 1998 and 2007,
which found: "Decreases in unemployment and increases
in average income in an area explained, to a large extent, why
some local authorities 'performed' better than others."[211]
In Sweden, the National Board of Health and Welfare (NBHW) told
us that it recognised three levels in public health: structural,
involving a person's education, participation in society and economic
circumstances; environmental, including people's workplaces and
their local residential areas, and lifestyle, such as their drinking,
eating and exercise habits. Bosse Pettersson, NBHW director, explained
that to tackle the lifestyle factors, they had to work through
the first two levels, because then they were able to see the connection
between, for example, unemployment and smoking.
Cllr Nick Forbes, leader of Newcastle City Council,
told us that his authority would focus at least some of its work
on unemployment,[212]
and Cllr Mary Lea, from Sheffield City Council, said:
We would like to see maybe more powers devoted to
local government so that we can tackle more of the social determinants
of poor health and inequalities. In particular, maybe we are looking
at the Work Programme. That may be something that we would like
to see devolved down to local authorities, because we think we
can maybe make a better job of that than is currently happening.[213]
In our report, Localism, we noted how the
Government's definition of the concept was sometimes stretched
and contradictory, and concluded:
Some policy areas appear to have been granted an
exemption from decentralisation. The priorities of the Department
for Work and Pensions appear particularly resistant to the arguments
for devolving power to local institutions, despite the eagerness
of local authorities to be more involved in shaping the response
to worklessness in their area.[214]
The Under-Secretary of State for Communities and
Local Government, Baroness Hanham, pointed out, however, that
on employment initiatives local authorities "already take
that responsibility […] supporting apprenticeship schemes
and looking after people that are not well, and encouraging them
back [to work]".[215]
92. We are pleased that local
authorities are looking at the evidence and adopting an evidence-based
approach to health and wellbeing. Evidence shows that being and
staying in work has a significant effect on a person's health
and wellbeing; unemployment is one of the causes of the causes
of poor health. It follows that a strategy to combat worklessness
might be one of their public health initiatives from April 2013.
This requires the Government and, in particular, the Department
for Work and Pensions to adopt a more localist approach and to
devolve more powers to councils, as we said in a report back in
2011. We note that local authorities already support apprenticeships
and back-to-work schemes, but the Government should consider devolving
to local government further measures, including elements of the
Work Programme, in order to address at a more local level unemployment
and, in turn, one reason why people may adopt unhealthy lifestyles.
Local authorities working with
the Government
93. The Government, in its White Paper, Healthy
Lives, Healthy People, stated:
Where the case for central action is justified, the
Government will aim to use the least intrusive approach necessary
to achieve the desired effect. We will in particular seek to use
approaches that focus on enabling and guiding people's choices
wherever possible.[216]
The Health Select Committee, when it examined public
health in 2011, however, found:
While interventions that involved the Government
"shoving people" (such as the ban on smoking in enclosed
public places) were demonstrably effective, nudging, which was
ill-defined ("a very flaky, slippery term"), was little
supported by evidence […] The recent report from the House
of Lords Science and Technology Committee has since confirmed
how thin the evidence base for nudging is, as well as the unevenness
of evidence between different fields of behaviour change.[217]
94. We considered whether the local initiatives
referred to in the previous section might, in some cases, require
additional and complementary central Government action. Dr Nicholas
Hicks, Director of Public Health in Milton Keynes, explained how
a target to reduce inequalities in infant mortality had been
supported by concerted action nationally. There were
public service agreements and every department bent its actions
to that, supplemented by freedom and incentivisation of local
authorities through local public service agreements.[218]
Dr Hicks explained that the target had been hit two
years early and said that "we do have examples of how, by
bending the totality of resources, not just this tiny sliver labelled
public health, we can do something that is genuinely wonderful."[219]
Other witnesses told us they would be working to engage the Government.
Cllr Mary Lea, of Sheffield City Council, said that one of her
authority's priorities was
to lobby Government in terms of some of the big health
issues that we face: for example, obesity, how food is produced
[…] manufactured […] advertised and sold. I think there
are some changes only the Government can make.[220]
On moving resources to prevention, Cllr Anthony Devenish,
of Westminster City Council, was reluctant to call it "lobbying"
but said
you have to communicate […] you have to get
your message across, and the value for money point […] is
that if we can prevent things through reducing binge drinking,
that is going to help the NHS overall.[221]
In relation to alcohol-related harm, Newcastle City
Council focused on the affordability of drink and was therefore
"campaigning as a council for a minimum unit price of alcohol".[222]
The Health Minister, Anna Soubry MP, told us of her initial scepticism
about a minimum price but revealed how she had subsequently met
liver specialists and doctors who "frankly blew me away and
completely convinced me that it is a thoroughly good idea."[223]
The Government's consultation on the matter finished on 6 February
2013.[224] The Government
is currently reviewing the results of the consultation.
95. Aside from consultation on proposed legislation,
the Government has also introduced the "Public Health Responsibility
Deal", a voluntary agreement by which businesses commit,
for example, to improving the health of their customers and staff,
or to helping them to become more physically active.[225]
The Department of Health has noted that many local authorities
already run local Public Health Responsibility Deals to encourage
such activity, and, working with the Local Government Association,
local authorities, local businesses and other organisations, the
Department is developing "a toolkit to support engagement
of local businesses to take simple actions in the areas of alcohol,
food, health at work and physical activity."[226]
On the next steps nationally in the Responsibility Deal process,
Ms Soubry explained that a "bit of naming and shaming is
going to happen, because we make it clear that, unless we begin
to see substantial changes, we will consider legislation".[227]
96. In Sweden, the NBHW told us that, on tobacco
control, it had recognised the need for input on three levels:
state level, which had set prices and an age limit on purchasing;
regional level, which as the provider of primary and secondary
care had introduced guidelines to ensure patients were ready for
surgery; and municipal level, which had responsibility for enforcing
the state's rules on price and age.
97. Some public health issues,
such as alcohol misuse and obesity, may require central Government
leadership and action, including legislation, if a big difference
is to be made to the health of local people. Central Government
action will not be a panacea, but to effect change local authorities
may require the support of complementary national-level initiatives
to make the most of their own strategies, powers and influence.
In the meantime, councils do have options available to them, including,
setting up or expanding local Public Health Responsibility Deals,
with local businesses, on which Government guidelines were published
in January 2013. What is clear is that there is no single solution;
multiple solutions will be required to deal with the multiple
causes of unhealthy behaviour.
JOINED-UP GOVERNMENT
98. In chapter 2, we cited Dr Mike Grady's point
that to address the social determinants of health, HWBs would
"need the right players in the right room to address the
right issue".[228]
We noted press reports on 8 November 2012 that the Cabinet sub-committee
on public health, which had been established to enable work "across
multiple departments to address the wider determinants of health",[229]
was being disbanded. Explaining the decision, the Cabinet Office
was reported as saying:
Public health issues will now be brought into the
broader domestic policy committees rather than sitting with a
separate subcommittee. This will allow public health issues to
be discussed and decisions to be taken by a wider group of ministers
from across government. [230]
When we asked the Government how and when public
health issues had been discussed and decisions taken by that "wider
group of ministers from across government", the Health Minister,
Anna Soubry MP, replied, "I do not know of any,"[231]
and Tim Baxter, from the Department of Health, said that "we
have plans for engaging with the Home Affairs [Cabinet] Committee;
The brutally frank answer is that we have not done so yet."[232]
Ms Soubry did add later in the session that she "went to
see Edward Timpson in the Department for Education to talk about
[…] the lack of physical activity in too many of our youngsters".[233]
99. Since the disbandment of
the Cabinet sub-committee on public health, public health issues
fall to be discussed and decisions taken in domestic policy committees.
We note also plans within the Department of Health to engage
with the Home Affairs policy committee, and the discussions that
the Department has already had with the Department for Education,
which should be encouraged elsewhere in government. Policy
alignment nationally will assist councils' efforts to improve
health and wellbeing locally and avoid the potential for mixed
messages. Given the way in which local health issues span at least
two Departments, Health and Communities and Local Government,
local authorities need confidence in their contact with Government.
In the spirit of close working throughout government, both
centrally and locally, we recommend that the Department
of Health and the Department for Communities and Local Government
set up a single point of ministerial contact to which local authorities
can turn for support in their new health care role.
Measuring success
100. The Government, as part of its health reforms,
has developed three frameworks from which bodies with responsibility
for health can identify the outcomes they would like to achieve
as a result of their work: the NHS Outcomes Framework, the Public
Health Outcomes Framework and the Adult Social Care Outcomes Framework.
The Government explained that:
The purpose of developing three separate frameworks
has always been to ensure focussed rather than blurred accountability
and to recognise the different delivery systems and accountability
models for the NHS, for public health and for adult social care
[…]
the NHS Future Forum presented a model in which it
should, in certain areas, be possible to set specific outcomes
for the different sectors that contribute to broader outcomes
that are shared between the different sectors. The Government
supports this model […]. However, the pace at which greater
alignment of this type can be achieved will necessarily be constrained
by current data and indicator availability.[234]
Dr Penny Toff, of the BMA, told us that the public
health outcomes framework "as a way of monitoring what is
going on locally" was "very sound", although to
encourage integrated working and to put aside "individual
agendas" she considered "it would probably be helpful
to have a more overarching national framework around integrated
care."[235] Tim
Baxter, from the Department of Health, cited the public health
outcomes framework as a systematic way of measuring success, highlighting
its 66 "wide-ranging" indicators on "things like
reoffending rates, school readiness, smoking prevalence, vaccination
rates and premature mortality."[236]
We noted earlier in this chapter how improvements in school readiness
rates could be a useful short-term measurement of success.[237]
In that context, we also heard that the figure for NEETs (those
not in education, employment or training) would demonstrate "within
a short period" whether an impact was being made.[238]
The Royal Town Planning Institute was, however, keen to expand
that indicator to include in the outcomes framework an overall
assessment of worklessness rather than just of NEETS, and to include
overcrowding and housing.[239]
101. Westminster City Council, while it found
the absence of clear objectives from the Government "provided
space for local authorities to determine local objectives which
fit local needs," noted:
Where the lack of national clarity may be problematic
is balancing the local approaches to public health with the Department
of Health's approach to measuring the impact of the new arrangements.[240]
Professor Gabriel Scally, of the University of the
West of England, told us that authorities would need to be able
to measure their data alongside a range of comparators, nationally
and internationally. For example, although in the south-west some
areas were better than the English average, this did not provide
a complete picture as "the overall position of England is
so much worse than other countries."[241]
He concluded that "people must be allowed to act within the
system in the interest of the population they serve", whether
the population of England or of a local authority.[242]
102. We also heard about the risks involved in
assessing what works. Newcastle City Council, while acknowledging
the importance of measuring health and wellbeing, and any changes
in inequalities in health and wellbeing, stated that
there is a risk such measurement becomes an end in
itself […]. Measuring impact in the short-term can lead us
to focus on individual interventions where there is a greater
evidence base, rather than enable us to use our energy and resources
to drive social change that will lead to sustained improvements
for wellbeing and health for this and future generations.[243]
Dr Toff made a similar point, telling us about the
lack of data on marginalised communities and when measuring, for
example, childhood obesity levels, not to ignore "what is
happening to groups that would not necessarily be included within
those measurements."[244]
Liam Hughes, the independent chair of Oldham's shadow HWB, said
that a key indicator of success "should be the scale of the
redirection of commissioning investment upstream into prevention."[245]
He accepted that "further upstream" into prevention,
it would be difficult to draw a direct link between cause and
effect, as any analyst would then be dealing with "the conditions
of life rather than some preventive intervention", but he
cited work in Oldham on premature mortality, to which we referred
in chapter 3, using the current figure for men dying and the direct
interventions that might reduce it, as an example of good evidence
and a targeted, measurable programme that the HWB was going to
implement.[246]
103. Mr Hughes also drew our attention to the
impact of external factors:
Many boards are concerned about the impact of major
policy changes on health, especially the welfare reforms […]
for some of the most vulnerable people in our society, the combination
of reduced income, more insecure housing and reduced support will
work against the grain of health improvement.[247]
Sheffield City Council pointed out that measuring
the impact of public health programmes on populations continued
to be a challenge:
This is because public health initiatives take place
in the context of continuing change within society, which in turn
impacts on health […]. Thus, for example, the current economic
recession is likely to have far more extensive impact (negatively)
on the health of the population than locally managed, relatively
poorly resourced, public health programmes.[248]
It also explained that it would use its resources
"to focus on interventions which are proven to make the biggest
impact on well-being".[249]
Some examples that drive home its point are shown below. Professor
Chris Bentley provided one example of a methodological intervention
that could be easily measured. He noted in Birmingham the correlation
between the incidence of people with heart disease and their non-registration
with a GP and, extrapolating that evidence to people with other
long-term conditions, explained that it was clear only half the
people with such conditions knew they had them. He therefore suggested
that all HWB partners could contribute to the solution by educating
the public about the issue, by searching for the "'missing
thousands" of non-registered patients and by helping them
to connect with the services available, explaining that as a result,
"GPs will then be able to improve their own performance in
relation to registering patients, and getting them on the best
treatment".[250]
104. The transfer of functions
from central to local government during the relocation of responsibilities
for public health must not become an end in itself. Local authorities
will need to provide within an agreed period evidence of an improvement
in the health and wellbeing of their population. With these new
powers comes the responsibility to deliver results, and local
authorities will need to balance local and national objectives
and short-term and long-term aims. Given the complex, multi-faceted
nature of the social determinants of health, however, determining
the success of general—population-wide—or specific
initiatives will be difficult, time-consuming and may ultimately
distract those working on them from making progress. Short-term
success can be demonstrated relatively quickly, and without distracting
from longer-term objectives, by, for example, improvement in readiness
for school rates, the number of NEETs (those not in education,
employment or training) in a local area and by all Health and
Wellbeing Board members working to increase patient registration
with GPs in order to identify those with long-term conditions
and to prescribe treatment for them.
ASSESSMENT BODIES
105. The relationship between the national and
the local in measuring success was also reflected comments on
who should conduct the assessment. Cllr Alan Connett, from the
District Councils' Network, referred to Healthwatch, scrutiny
committees and ultimately the electorate as the bodies that should
hold local authorities to account.[251]
Cllr Steve Bedser, from the LGA and Birmingham City Council, said
he was "reluctant to be held to account from day one, because
in some local authorities we inherit very stark inequalities",
but he also said "health scrutiny and Healthwatch are going
to be very important in keeping some local temperature".[252]
Dr Peter Carter, of the Royal College of Nursing (RCN), cited
hospitals at the bottom of league tables which "feel quite
persecuted by it, when it is often a reflection of the population
they are serving […] In the first few years […] we need
to be careful not to set unrealistic targets for local authorities,
because this is about behavioural and lifestyle change."[253]
Liam Hughes, from Oldham's shadow HWB, said that PHE was "conscious
that the switch from top-down direction to sector-led improvement
requires first-rate data and intelligence, the identification
of blind-spots, and the will to take action about them."
He added that PHE should therefore "be more of an ally and
'critical friend' than a regulator".[254]
106. Good local authorities
may already be tackling the difficult challenges posed by unhealthy
people and communities, so in the short term at least it would
be unfair and possibly counter-productive to start "naming
and shaming" councils without taking into account historical
and demographical factors. With Public Health England in its infancy
it makes sense to restrict its role to that of critical friend.
On matters of scrutiny and regulation, local authorities should
not hide behind a national body such as Public Health England.
We encourage them, in the spirit of localism, to take responsibility
for these issues themselves, through overview and scrutiny committees
and Local Healthwatch.
SELF-ASSESSMENT
107. Witnesses drew our attention to one aspect
of measurement, self-assessment, as an effective means of both
obtaining information about people and involving them in their
own care. Caroline Abrahams, of Age UK, told us that, because
older people when asked had included social contact in their definition
of wellbeing, it was important to measure their levels of participation
in society, adding, "you could do that through surveys […]
working with and through voluntary sector organisations."[255]
Paul Woodward, of Sue Ryder, agreed, telling us that its younger
service users also had broad ambitions, to maintain their independence,
spend time with their family and engage with the community, adding
that "you could certainly look at that through surveys"
and that he saw no way of measuring it "other than asking
people whether they are actually getting it or not."[256]
This idea of making the most of the knowledge of service users
as well as providers was, Dr Mike Grady told us, an element in
the co-production of health and wellbeing which "encourages
people and communities to participate in public services on an
equal basis with professionals".[257]
108. Surveys—self-assessments—are
a useful measure of wellbeing: they quantify the less specific
but no less important objectives of independence and social participation,
and they engage individuals in the development of their own wellbeing.
Councils might make such surveys one aspect of agreeing their
contracts with voluntary groups.
184 Ev w6, para 10 Back
185
Ev w6, paras 5, 11 Back
186
Q 3 Back
187
Q 238 Back
188
Q 235 Back
189
Ev 127, para 1 Back
190
Q 3 Back
191
Ev 160 Back
192
Q 232; the King's Fund also explained that separate strategies
to tackle different examples of unhealthy behaviour had not worked,
because "unhealthy behaviours co-occur and cluster in population
groups, particularly in the most disadvantaged populations,"
and concluded: "Local authorities, with their greater knowledge
of local communities-and their greater control over some of the
economic and social conditions that shape behaviours-should be
in a better position to do this than the NHS", Ev 78. Back
193
Q 170 Back
194
As above Back
195
Planning Use Class Orders, Standard Note, SN/SC/1301, House
of Commons Library, January 2013 Back
196
Planning Use Class Orders, Standard Note, SN/SC/1301, House
of Commons Library, January 2013 Back
197
Local Government Information Unit and Westminster City Council,
A dose of localism: the role of councils in public health,
p 6 Back
198
"Obese who refuse to exercise 'could face benefits cut',"
BBC News Online, 3 January 2013 www.bbc.co.uk/news/uk-england-london-20897681 Back
199
Local Government Information Unit and Westminster City Council,
A dose of localism: the role of councils in public health,
p 5 Back
200
Q 290 Back
201
Ev 164 Back
202
Q 305 Back
203
The Marmot Review, Fair Society, Healthy Lives: Strategic Review
of Health Inequalities in England post 2010, p 39 Back
204
The Marmot Review, Fair Society, Healthy Lives: Strategic Review
of Health Inequalities in England post 2010, p 60 Back
205
Q 287 Back
206
As above Back
207
Q 170 Back
208
Q 232 Back
209
Q 170 Back
210
Ev 120, paras 22, 23 Back
211
Ben Barr, David Taylor-Robinson and Margaret Whitehead, "Impact
on health inequalities of rising prosperity in England 1998-2007,
and implications for performance incentives: longitudinal ecological
study", British Medical Journal, 2012, ref: 335:e7831,
p 1 Back
212
Q 214 [Newcastle]; see also Ev 120, para 22 [Westminster] and
Q186 [Sheffield]. Back
213
Q 199 Back
214
Communities and Local Government Committee, Third Report of Session
2010-11, Localism, HC 547, para 32 Back
215
Q 381 Back
216
HM Government, Healthy Lives, Healthy People: Our Strategy
for Public Health in England, CM 7985, para 2.33 Back
217
Health Committee, Twelfth Report of Session 2010-12, Public
Health, HC 1048-I, para 277 Back
218
Q 36 Back
219
Q 36 Back
220
Q 170 Back
221
Q 221 Back
222
Q 170 Back
223
Q 321 Back
224
A minimum price for alcohol?, Standard Note, House of Commons
Library, SN/HA/5021, 12 February 2013 Back
225
Department of Health, "Public Health Responsibility Deal:
Core Commitments", responsibilitydeal.dh.gov.uk/ Back
226
Department of Health, "A toolkit for supporting engagement
with local business", responsibilitydeal.dh.gov.uk/ Back
227
Q 324 Back
228
Q 228 Back
229
HM Government, Healthy Lives, Healthy People: Our Strategy
for Public Health in England, CM 7985, November 2010, executive
summary, para 4 Back
230
"Doctors dismayed as public health committee is scrapped",
The Guardian Online, 8 November 2012, www.guardian.co.uk/politics/2012/nov/08/doctors-dismay-public-health-committee Back
231
Q 326 Back
232
Q 327 Back
233
As above Back
234
Department of Health, The NHS Outcomes Framework, 2012/13,
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf Back
235
Q 63 Back
236
Q 386 Back
237
See "Early years" section in this chapter, and Q 227
[Dr Mike Grady]. Back
238
Q 227 [Dr Mike Grady] Back
239
Q 135 [Richard Blyth] Back
240
Ev 120, paras 14-15 Back
241
Q 64 Back
242
Q 65 Back
243
Ev 123 Back
244
Q 69 Back
245
Ev 125 Back
246
Q 217 Back
247
Ev 126 Back
248
Ev 131, para 36 Back
249
Ev 127, para 6 Back
250
Ev 154 Back
251
Q 72 Back
252
Qq 72, 74 Back
253
Q 75 Back
254
Ev 125 Back
255
Q 143 Back
256
Q 146 Back
257
Ev 148 Back
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