Once in a lifetime opportunity

Powers to tackle public health issues are being handed down to the local level. But will it bring about the fundamental shift needed to finally tackle inequality? Clare Goff reports

These three siblings are among the thousands who have participated in the Born in Bradford study

Since 2006 every baby born in Bradford has been invited to be part of a study aimed at unpicking the city’s poor health record. Currently 13,000 babies are signed up to Born in Bradford, half of whom have Pakistani heritage and half of whom are white, mirroring the city’s ethnic mix.

Believed to be the biggest bi-ethnic study of its kind, Born in Bradford is hoping to use the data to discover why, in a city in which infant mortality levels are twice the national average, babies from south Asian families are more likely to die as infants than their white counterparts.

As the data builds up, professor of health research at the Bradford University, Nick Small, is hoping that it will be able to pinpoint the exact causes behind the high mortality levels of babies of Pakistani heritage in the city. While infant deaths often relate to exposure to smoke and alcohol, parents of Pakistani origin are less likely than their white counterparts to smoke or drink, pointing the way to deeper issues.

‘I think it’s something to do with greater levels of maternal poverty – damp housing, problems with pollution, lack of money,’ says Professor Small. ‘We’ll look at each death and try to find out what exactly killed that baby.’

Born in Bradford researchers are beginning to work with regeneration teams in the city and to collect further data on the babies as they begin school and grow up, providing a unique resource for the city.

Health campaigners have long argued for a more rounded approach to public health that takes into account its complexities; through this study the city of Bradford will begin to understand the particular health needs of its citizens, focus in on inequalities and discover how factors related to place – from the number of green spaces in the city to levels of employment and income – impact on health.

A LOCALIST APPROACH
Such a focused and localised approach to public health is what the government is hoping for through the publication of its public health white paper, Healthy lives, healthy people, last November.

Its proposals for the re-organisation of public health shift responsibility from the NHS to local authorities. From 2013 councils will receive ring-fenced funds and a director of health will sit within the council and work in partnership with the local NHS and across the public, private and voluntary sectors through local health and wellbeing boards.

The plans set out put ‘local communities at the heart of public health’, the white paper says.

Local areas will be free from much of the nationally driven policy and targets which, under the current regime, saw areas with low teenage pregnancy levels forced into setting up partnerships to tackle the issue.

Instead, the emphasis is on understanding and being reponsive to the needs of local communities. Empowered local areas will be able to respond to specific health issues – whether they be high rates of infant mortality or alcohol consumption. There is a focus on the importance of locally relevant data, both of the issue and of what works.

‘There are lots of reasons for it to make sense,’ says Charles Lauder, director of Talewa Consulting, which focuses on equality and diversity issues. ‘Local councils can make interventions into housing and education, which relate to health. You need to find somewhere where all those things matter and they matter to the local authority.’

The new approach could bring a broader awareness of the complexities of health and recognise that it can be impacted in ways that sit outside traditional health services.

The localist approach will by necessity be a more patchy affair, however.

‘History means that there are different starting points for different areas,’ says Nigel de Noronha, an independent consultant. ‘Some are putting health inequalities at the heart of planning at the local strategic partnership. Others are away with the fairies, doing heavy statistical epidemiological studies. The changes will mean different things for different places. For some it will be organic, for others not.’

BIG SOCIETY ALONE WON’T TACKLE INEQUALITIES
In the context of cuts, there is a fear that some authorities will find ways to raid the ring-fenced public health funds, or take a reductionist approach and avoid the nuances and complexities of the agenda.

Ring-fencing the public health budget seems to go against the multi-faceted approach that placing health within a local authority could bring. Practitioners are warning councils against setting up a separate department for public health; allowing health to intersect with housing and employment for example will allow for a more rounded and place-specific policy.

Although the white paper emphasises the equalities agenda, many fear the funds and years of amassed learning in the area will be stripped away as budgets are squeezed.

The dismantling and reform of the NHS that is taking place alongside the public health changes will create a gap in knowledge and expertise, and extra funding pots around equalities are coming to an end.

Oldham, for example, has produced one of the most significant reports into health inequalities in recent times; some of its findings highlight the challenge that many local areas – particularly those with high black and ethnic minority populations – face.

For, while the health issues which impact on these communities – such as cancer and heart disease – are the same as those which impact on the population as a whole, the Oldham report found that the impact of these diseases on BME populations is disproportionately large.

There is likely to be a thinner coating of jam for such work in the future, as cuts take effect, equalities work moves into the mainstream and the Big Society agenda come on board.

‘Active citizenship’ is no replacement to the highly targeted work that has helped make inroads into health inequalities in recent years.

For re-balancing health inequalities is about changing people and communities.  Without robust data and information on who and how different groups are impacted by health inequalities – and evidence of what works – it will be those with the loudest voices that will benefit most.

As the new agenda rolls out, finding ways to engage maginalised communities will become ever more important.

‘If the changes are to work communities need to understand them, understand their part in making them work and the need to get out amongst them,’ says Mr Lauder.

Local people taking part in the Our Life inquiry in Blackburn

Our Life Northwest uses deliberative engagement processes to help pinpoint and tackle the health issues of some of the poorest areas in northwest England. Its Citizen Juries are proving effective at getting evidence of the issues and building on-the-ground advocates of change around issues such as food and alcohol.

Community engagement at this level takes time and energy, however, and will not be an easy sell during years of austerity. But years of learning in this area shows that it is worth the price. Helping people and communities understand and prevent health issues is too important to be left to chance – or to markets.

NUDGE IS NOT ENOUGH
The government has its own ideas for how behaviour can be shifted, moving from ‘nannying’ to ‘nudging’. Techniques such as providing fruit sections in shopping trolleys to ‘nudge’ people into buying more vegetables often work well for middle class people with greater freedom to choose and articulate choice, but for marginalised people with tight weekly budgets, choice is a luxury.

And there is the rub. As the Born in Bradford study – and countless studies before it – have proved, the strongest determinant of health outcomes is money; strengthening local economies, boosting jobs and protecting the most vulnerable will impact on health inequalities much more than any ‘nudge’ approach.

As a recent report from the New Economics Foundation details, the best – and most efficient – impact local councils can make into the health and wellbeing agenda is to give it a central role in local government.

Council leaders need to create a compelling overarching vision for health and wellbeing, it says; allowing health to cut across everything it does will not only improve the lives of its citiizens but will also save money in the long term.

Examples of how such an approach could work are now being seen. Liverpool declared 2010 the year of health and wellbeing, supported by the council, primary care trust, local businesses and third sector groups. Councils in partnership with local PCTs in the north west jointly funded a survey to measure mental wellbeing of the local population, while Nottingham and other councils have used their procurement budgets to strengthen local economies and boost wellbeing in the process.

As cuts, rising unemployment and a more punitive benefits system begin to impact on places, councils will need to respond imaginatively to prevent the knock-on impacts on health.

Local areas are being handed greater control over local public health outcomes; the challenge will be to place health at the heart of creating strong and resilient local areas.