Select Committee on Health Appendices to the Minutes of Evidence


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, J, Jousilahti, P. (1994). Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. British Medical Journal, 304, 23-7. Back

78   Ness, A R and Powles, J W (1997). Fruit and vegetables, and cardiovascular disease: a review. International Journal of Epidemiology, 26, 1-13. Back

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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