Public Health England – How helpful is Longer Lives?
Its difficult being a new organisation – particularly when you are so close to your main funder that it is hard
to see where the join is. This is the problem faced by Public Health England.
Public Health England is an Executive Agency of the Department of Health this means that while it is treated as being managerially separate from the Department it does carry out some of the executive functions of Government.
So, when Public Health England announces something we should see this as being as a Government Position.
So the announcement on Tuesday the 11th of “Shocking” local variation in early death rates across the country appears to be official recognition that health inequalities is still an issue of real concern to Government…..except that health inequalities is not mentioned at all.
What I want to focus on is how the data is presented and what the underlying message is – because this information sets the tone for government discussions with local authorities and will be the information that Directors of Public Health in particular will be taking into Health and Wellbeing Boards.
The Big Killers
Despite Government commitment to give equal weighting to mental health (see foreword of No Heath without Mental Health) the Longer Lives website ignores this and instead focusses on the old medical public heath favourites of Cancer, Heart Disease and Stroke, Lung Disease and Liver Disease. These are all presented with regard their impact on early death.
So, in this the first significant product from Public Health England for local authorities and Health and Wellbeing Boards the early messages are:
- Its early death not long term illness
- Its physical health not mental health
Blame the Poor
As well as the focus being on “the big killers” the proposed interventions are weighted heavily towards lifestyle three quarters of the interventions focus on behaviour change. In other words teaching and persuading people to accept their circumstances and improve their behaviour. The graph below shows that of the proposed interventions approximately 3/4 focus on lifestyle change. (My workings out are here – PHE Blog)
Collectively they give a very dubious message to Health and Wellbeing Boards which is:
- Prioritise telling people to live more healthily
- Don’t worry about how they feel
- Don’t worry too much about their socio economic circumstances
Comparing apples with pears
I think that the way the data is presented replicates a mistake made bythe last government which grouped those local authorities with the greatest health inequalities compared to the national average into ‘spearheads’. This meant that local authorities with a large middle class population and a large deprived population appeared to be less challenged than those with where the majority of people were deprived – even though they might have more people who were experiencing inequality.
The way the data is presented feels inaccurate because it is comparing average premature mortality at local authority level. This means that very deprived communities within local areas can be masked by more affluent ones.
What happens next
Local Authorities and Health and Wellbeing boards are working on much broader approaches to improving health and wellbeing that recognise the importance of mental health and the impact of the social determinants of health. It will be important that the governments narrow view of priorities and how to tackle them does not divert them from this agenda.
What do you think?
Lots of good points here, many of which I agree with. However, to answer the question posed by your headline, I think publication of this data in this form is both helpful and important. Just publishing the data in way that is accessible gets people – ordinary people who are not experts – talking about important issues they were not talking about before. None of the data published is new. Experts have been well aware of it, but ordinary people (including many senior decision-makers) were probably not, because it was hard to get at and presented for an expert audience only. You are clearly worried that the way the data is now presented will mislead people, but there are plenty opportunities to point this out – as you do here. The important thing is that data like this, once available only to experts, can now be consumed by everyone – and in my book that is a good thing.
Lots of good points here, many of which I agree with. However, to answer the question posed by your headline, I think publication of this data in this form is both helpful and important. Just publishing the data in way that is accessible gets people – ordinary people who are not experts – talking about important issues they were not talking about before. None of the data published is new. Experts have been well aware of it, but ordinary people (including many senior decision-makers) were probably not, because it was hard to get at and presented for an expert audience. You are clearly worried that the way the data is now presented will mislead people, but there are plenty opportunities to point this out – as you do here. The important thing is that data like this, once available only to experts, can now be consumed by everyone – and in my book that is a good thing.
Useful points and distinctions, and yes I share your concern re a narrow view of priorities steering things away from even more things which are difficult to tackle. I watched this TED Talk about obesity tonight, and it really got me thinking http://www.ted.com/talks/peter_attia_what_if_we_re_wrong_about_diabetes.html
What you point out about a focus on behaviour change resonated somewhat with this for me. What if we are wrong? Is the science good enough?
Hi Mark
I was one of the ‘technical architects’ on the DH Health Trainer project. Since then a few of us have been trying to raise awareness of health literacy (or rather lack of it) in the population as a whole. If people don’t understand what health professionals are telling them or what they are reading they have no chance of improving their health and/or life style. If you look at the literature if it is a frightening percentage of people that this applies to – even the people you would expect to have knowledge often have little understanding of how the body works.
Thelma Harvey
Longer Lives is primarily a re-cycling of existing information that should already be familiar to many local authorities through the inclusion of the data in the Director of Public Health’s Annual Report and the local Joint Strategic Needs Assessment (JSNA).
The ‘league table’ approach whereby areas are compared with their nearest neighbours in terms of deprivation ranking is a blunt tool that fails to reflect the complexity of deprivation as a concept and does not take in to account external factors such as levels of public health and NHS funding relative to health need (equity) and funding for instrastructure improvement and research (especially medical research).
From a statistical point of view, our analysis of the data suggestsd that the standardisation process understates the effect of relatively low mortality in healthy young adults and overstates the effect of mortality in relatively unhealthy 45-75 year olds. The figures also fail to reflect any improvements in premature mortality that have occurred over the last decade (2001 to 2011) or the performance of local agencies in delivering preventive activities.
Having said that, the tool does have some value in reinforcing existing messages regarding the importance of continuing to prioritise health improvement activities at a time where the call on increasingly scare local authority resources are greater than ever.
I too share a lot of Mark’s concerns and the mixed response of the local government community, and the LGA in particular, to what were perceived to be a league table emerging is significant. PHE has a major job to do to convince local government that it is truly there to support and encourage and not to performance manage the sector. Trust will be at a premium. The term ‘sector led improvement’ is critical here as it is for local authorities to take the initiative to improve their performance and not be bullied into doing so in the way the NHS has been traditionally. The real issue is what were the drivers and motives underliying publication of the data, all familiar stuff as people have commented, at this time? Were they genuinely to help local authorities with their task or were they issued to signal to local authorities that unless they take action then PHE, as the arm of government, will ‘name and shame’ or pull whatever other lever may be available to it? It would perhaps have been smarter if PHE and the LGA together had published the data in a way that made it clear what it’s purpose was. It’s very hard to gain trust but easy to lose.