How To Help The Environment

Transcription

1 The Chair: Dr Sue Atkinson is the London Director of Public Health. She is going to address the Committee on Health Issues for London - that s the first part of her presentation - and the next part will be Dr Atkinson addressing the Committee and informing the Committee about Infant Immunisation, and that is at Appendix A of the agenda. Sue, thank you very much indeed for coming along. We really appreciate the time you are giving us. It s over to you. London s Health- An Overview London s big health issues Health inequalities London s health challenges National and Regional context Working with GLA to improve health Dr Sue Atkinson (London Director of Public Health): Thank you very much and thank you for inviting me to come and speak to you today. Health Issues for London What I want to cover in this first presentation is an overall picture of London s health: what are the big health issues?; special issues around health inequalities in London; therefore, what are the health challenges?; some of the national and regional context; and then some of the work that we ve been doing about improving health because, in fact, we are unique in having the GLA here. 1

2 London s Population 7.4 million people almost 1 million commuters estimated 30 million tourist each year rich and diverse cultures.300 languages 25% from black and minority ethnic communities high proportion of young people and those years population projected to grow significantly London s population, obviously, is the background to what s on in terms of health. 7.4 million people; 1 million commuters; 30 million tourists every year. Most importantly, a city of amazingly rich and diverse cultures with over 300 languages spoken and 25% of the population from black and minority ethnic communities. These are significant because the health issues in London obviously are different if you have different populations as part of the package. There is a very high proportion of young people in London, both and year olds. And as you will know from the London Plan the population is projected to grow very significantly. Slide 4 14 AGE DISTRIBUTION OF POPULATION BASED ON 2001 Census/MYE Persons by Age Band as a percentage of Total Population % of Total Population < Age Band, years England & Wales Gr eater London Inner London Outer London This is a picture of the population and how it compares to England and Wales. You can see here the red peak is inner London and is the peak in the year olds. As you see, particularly in inner London but in London as a whole, it s much higher than the average is in England and Wales. We actually have a smaller elderly population. That is 2

3 significant because it s reflected in some of the patterns of diseases and illnesses that we have in London. London s Health Determinants This is a chart, not devised by me, but a very well used one by public health people, which is very much around what are the things that make a difference to people s health, what we would call the health determinants. And, as you will see, the little picture of people standing in the middle is around their individual factors: how old you are; what sex you are; your constitutional factors - what your genes are like, and so on - makes the difference to how healthy you are. Then there are individual lifestyle factors and the common ones we think of there are, obviously, around things like smoking - it makes a huge difference to what your pattern of health will be through your lifetime. The next circle is around social and community networks, and there is now increasing evidence that how many connections you have, and how well connected and well supported you are, makes a very big difference; not just to your social and psychological wellbeing but also to your physical health. Again, this may be very important when we re looking at some of the particular issues in London like, for example, teenage pregnancy; we need to make sure those young people have the appropriate social and community networks to give them support. The next circle picks up a variety of things that are very pertinent to your health, and some of them are very obvious like living and working conditions; whether you ve got clean water and sanitation - not something we think about usually in London but more common in third world countries - but unemployment, critically important; and education, critically important. Very clear patterns of better education; more able to demonstrate skills; more able to get work; and, therefore, maintained in work and a healthier outcome. These patterns are very clear. Again, housing and food are very important, and the health care services. As I think I have often said, I like showing this slide to people in the NHS because it demonstrates that, whilst health care services are important, they are only one of many factors that actually determine how healthy people are. 3

4 Finally, in the outside circle: general socioeconomic, cultural and environmental conditions. People, I think, increasingly aware of environmental conditions and the importance of those on health, but also, things like opportunities to be involved in cultural activity, and your general socioeconomic status is very important for your health. We do have very big differences across London in this. For example, on unemployment rates, there is a huge difference between Tower Hamlets and Richmond and Sutton, and even within some of our black and minority ethnic groups, we will see very different patterns of unemployment. For example, people generally from the Indian subcontinent, very similar unemployment rates to white people at around 5%-6%, but in the Bangladeshi community, huge unemployment rates of 24%. So, even within our black and minority ethnic groups, there are very different patterns within there, and very different patterns across London. INDEX OF MULTIPLE DEPRIVATION 2000 : LONDON WARDS IMD : Ward values 70 to 80 (8) 60 to 70 (35) 50 to 60 (70) 40 to 50 (87) 30 to 40 (129) 20 to 30 (157) 10 to 20 (180) 0 to 10 (116) One of the things that is archetypal in London is the juxtaposition between affluence and poverty, affluence and deprivation. This picture is a picture of multiple deprivation by London wards, and although you can see that most deprivation is concentrated in the inner city area and the east and north-east of London - those areas which we know are the regeneration areas - there are also often pockets of deprivation, even sometimes at sub-ward level. So, there will be a little pocket of deprivation, and one knows that if you walk almost anywhere in London, you can go from very affluent streets to very deprived streets in a short walking distance. 4

5 120 Inequalities in the Health of Londoners : Deprivation and Mortality 115 Barking & Dagenham Newham SMR All Ages, All Causes Lewisham 110 Tower Waltham Forest Greenwich Southwark Hamlets 105 Lambeth Sutton Ealing Islington Hackney 100 Wandsworth Brent Havering Kingston Hounslow Hammersmith Haringey Bexley Croydon upon Thames & Fulham 95 Enfield Merton Redbridge Camden Barnet 90 Hillingdon Bromley 85 Harrow Richmond upon Thames 80 Kensington & Chelsea 75 City of Westminster London Index of Multiple Deprivation But there is a correlation between inequalities in health, deprivation and mortality, and this graph shows it, with, at the top end of the graph, boroughs like Newham, Tower Hamlets and Hackney, with higher deprivation and higher mortality, and at the other end, boroughs like Kingston and Richmond and the City of London and Bromley. So there is a very clear gradient about deprivation, mortality and health. It is those inequalities that are really striking in London. Whereas we might have the same averages, if you look across London as the rest of England and Wales, what we see on almost any parameter is the huge discrepancy between one end of the range and the other end of the range, in almost everything we look at. Slide 8 Health Inequality Target: to reduce the gap in life expectancy at birth Nationally, we have got two inequality targets: one is about life expectancy at birth - how long you are expected to live - and this is a picture again of boroughs or PCT level. The life expectancy in years varies from the red patches, which are less than 73 years, to blue patches, which are 77 years and over. Just in the fairly short distance between 5

6 Newham and Westminster there is a six-year difference in the life expectancy of men. Those sort of features are repeated in almost any marker that we pick out. Health Inequality Target: to reduce the gap in infant mortality This is one for infant mortality and, again, we get a similar picture with more red towards the inner city areas but, again, a huge range between 3.6 in Bexley and 8.9 in Hackney for infant mortality. So, it is these overall pictures of deprivation, next door to affluence, but also of these wide gaps that we need to address, and the national targets are focused on addressing those. Main causes of illness and early death Coronary Heart Disease: leading cause of death: 16,000 deaths each year in London, Stroke responsible for another 7,000 deaths each year. Cancers: 1 in 4 Londoner s die of cancer, totalling 15,000 each year, 3,600 of these are smoking related. Poor diet plays a part in 1/4 of all cancers If I can swiftly skip through what are the main causes of illness and early death in London, they are coronary heart disease and cancers, the same as elsewhere. 16,000 deaths each year in London and a further 7,000 from strokes related to heart disease. And cancers, 1 in 4 people will die of cancer - that s 15,000 people each year - and over 3,500 of those are smoking-related and in another quarter, diet may well play a part. 6

7 Those are critical for some of the actions we re taking, particularly around smoking cessation, but also we have fairly recently launched a Schools Fruit Programme, where every child, 4, 5 and 6-year old, is being encouraged to eat a piece of fruit a day to encourage them to learn to eat in a more health way. Main causes. Respiratory Diseases: one of most common forms of ill health, leading cause of hospitalisation. Asthma affects 19% of school children by age 7 years. There are 3,500 potentially avoidable deaths in under 65 year olds each year from all causes. One of the other main causes with disease is respiratory illness. Asthma, as many people will know, has been on the increase in children for some time but 11% of adults have asthma diagnosed. Respiratory disease is a major cause of death, particularly in older people. In fact, when we were looking at some of the issues around transport and health, we found that the pollution from some of the congestion was more likely to affect older people and cause more deaths than we had from road traffic accidents in London, probably, to some extent, because the traffic travels so slowly, and so it may cause injury but not death. There are over 3,500 what we call, potentially avoidable deaths, in under-65 year olds and that is from things that ought to be able to be treated, ought to not cause death in this day and age. They will include things like high blood pressure, cancer of the cervix, TB, asthma and some treatable cancers. We ve got a way to go as well on some of the more common diseases which really, in this century, should be treatable. 7

8 London s Health Challenges Tuberculosis: London accounts for 43% of notifications in England and Wales HIV/AIDS: London accounts for 67% of all diagnoses of HIV ever made. Numbers living with HIV is projected to rise from 14,000 in 2000 to 18,000 in 2003 Mental illness: were 158 compulsory admissions under MHA in London, compared to a range of in other regions Drug misuse: 30% of England s recorded spend on drug problems occurs in London. Some special features of London that are particular challenges for us are that we do have higher rates of certain illnesses and of certain health issues. Tuberculosis - and, in fact, there s a conference happening today - London has 43% of the overall cases in England and Wales and we ve been seeing a rise in this over the last few years. It is a worry and we need to get on top of it. Again, we ve got quite a lot of programmes in place to try to address it. Sexual health and HIV and AIDS, again, a very high number of the total AIDS and HIV cases are in London. The projected numbers are due to rise, partly because of better survival from the new drug treatments, and so we will have more people living with HIV in London over the next year. Mental illness: again, a higher proportion in London than elsewhere in the country and, particularly, a higher number of admissions under the Mental Health Act, and of serious mental illness. Finally, picking up on this slide, drug misuse, which, again, 30% of England s recorded spend on drug problems occurs in London because that is where the high levels are. 8

9 National Context Saving Lives: Our Healthier Nation National Targets on Health Inequalities Cross Cutting Review of Health Inequalities Forthcoming National Health Inequality Action Plans NHS Priorities and Planning Framework Saving Lives: Our Healthier Nation is the national strategy which identifies the inequalities and picks up the national targets for health inequalities that I ve already talked about. There has recently been a Cross Cutting Review of Health Inequalities and this is really going back to that first rainbow-shaped slide I showed, demonstrating that lots of other things actually have a major impact on health inequalities. There will be an Action Plan coming out on inequalities which will not only be relevant to the NHS but also to other sectors, such as education and housing and so on. It is important that we see what that is when it comes out. NHS Planning and Priorities Framework NHS contribution to Reducing Health Inequalities: ensuring the benefits of service expansion favours traditionally under-served communities ensuring service planning is informed by equity and public health priorities tackling wider determinants of health building capacity for public health improvement Finally, recently come out through the NHS, is our Priorities and Planning Framework and that does cover a three-year programme, over the next three years, and these are some of the specific things in it to reduce health inequalities. The NHS must contribute to reducing health inequalities by making sure that we are picking up the traditionally under-served communities and I know that the Health Committee has been doing a Scrutiny on Access to Primary Care. This is obviously very 9

10 relevant to that and I am looking forward to the results from the Committee because I think that will help to inform what are the under-served communities in London and what should we doing about them, at least in respect of primary care. To make sure that public health priorities, such as the cardiac and cancer issues, are informed by equity because we know, at the moment, we do not necessarily have equal services for equal need. Tackling the wider health determinants - as I have demonstrated - and building our public health capacity, particularly with many of the changes that have just happened within the NHS with the organisational change. NHS Planning and Priorities Targets for Reducing Health Inequalities To reduce smoking during pregnancy To increase breastfeeding To reduce levels of teenage pregnancy To reduce death rates from CHD To reduce death rates from Cancer To increase uptake of flu immunisation among people 65 years and over. So, specific targets are around reducing smoking, particularly during pregnancy, and particularly in deprived groups; increasing breastfeeding; reducing the levels of teenage pregnancy - I think I mentioned those in passing but there is a special programme on that - and we do have high levels of teenage pregnancy in some parts of London; reducing deaths from coronary heart disease and cancer; and uptake of flu immunisation in people over 65 which, again, we know is particularly important for people with respiratory disease and to prevent deaths from flu. 10

11 Regional Context White Paper on Regional Governance, 2002 Proposes a public health role for Regional Elected Assemblies, based on the GLA experience Duty to promote health within the Region Produce a Health Improvement Strategy for the Region Regional Director of Public Health as health advisor to the Assembly There has also been a White Paper recently on Regional Governance and I think this picks up some of the good examples that have been set by the GLA and the Assembly on a public health role for regionally elected assemblies. So the same sort of focus on improving the health of London will be true for all the other regional assemblies as they come through. That is the duty to promote health within the region. Producing a Health Improvement Strategy: fortunately we have already started to do that. Again, that the Regional Director of Public Health should act as the health advisor to the Assembly and, as you know, I am both Regional Director of Public Health for London and Advisor to the GLA. That, again, is building on the experience we have had here. London Context London Health Strategy London Health Commission London Health Observatory Health Impact Assessment For London, as I mentioned, we have already developed a Strategy; we put this into place, starting in 1999, working with all the various sectors and partners to address the health inequalities and other issues that I have outlined; we have moved that on to be the London Health Commission and Elizabeth and others are members of that Commission. The London Health Observatory is a mechanism for us to examine some of the information and data and that helps to support the Commission in its work. The 11

12 London Health Commission has a conference coming up on 14 November, which I am sure you are aware of, but I think that will be an important day for us to take stock of the anniversary of the Commission and what the next step will be. I think some of the health inequalities issues that I have outlined today, really bring home how this cannot be achieved by just the NHS alone. Health Impact Assessment I will just mention because we have developed methodologies, particularly about what are the health implications of other strategies, and we have focused through the Health Commission on the strategies that the Mayor has been developing, so, for example, as the Strategies on Transport, Noise and Waste and so on have come through, we have done health impact on each of those. I think those have been quite successful in being able to influence the Strategies to take more account of what the health issues are. London s Health Commission: Priorities Inequalities Regeneration - economy/environment/buildings/people Black and minority ethnic issues Transport Plus considering : Children Disabled people London Health Commission has focused on a number of priorities: inequalities; regeneration; black and minority ethnic issues; transport; and it is now considering focusing on children and disabled people and, as I say, at the conference there will be workshops on that. 12

13 London Health Strategy High Level Indicators Unemployment rate Unemployment rate among black and minority ethnic people % pupils achieving 5 GCSE grades A-C Proportion of homes judged unfit to live in Burglary rate per 1000 resident population Air quality indicators - NO2 and PM10 Road traffic casualty rate per 1000 resident population Life expectancy at birth Infant mortality rate Proportion of people with self-assessed fair, poor or bad health In order to see where we are going in London and to know whether things are getting better or worse, we, as part of the London Health Strategy, identified ten high level indicators. As you will see from these, they are not just covering very focused health and disease issues - although there are one or two in there about life expectancy at birth and infant mortality - they also pick up issues like unemployment and school achievement - GCSE grades - to make sure that we are picking up these broader aspects of health. There was a report on these, commissioned and produced by the London Health Commission, and that gives us a baseline picture of where we are at. Again, in some of these, we do see the wide variations. For example, on the unemployment rate, 1.7% in Sutton and Richmond, but 11.6% in Tower Hamlets. Again, these demonstrate the same wide variations as we see in the more health-focused parameters. Working with the GLA to improve Londoner s health RDPH as Health Adviser Mayor s Strategies Assembly s Scrutiny role GLA Health Policy Team Project Work NHS engagement And finally, I want to pick up some of the work that we have been able to do between both the NHS, my own role as Regional Director of Public Health, the wider sectors and with the GLA. Clearly, myself as Health Advisor, the Mayor s Strategies - and I have talked a little bit about the Health Impact Assessment - the Assembly s scrutiny role, and I very much welcome that we have now got a Health Committee specifically. I work very closely, and my team work closely with the Health Policy Team within the GLA. There is specific project work that we have, for example, on the Health Impact Assessment; on a programme of saving Londoners lives; on coronary heart disease; on 13

14 some of the European comparisons through the Megapoles project and the alcohol action that we are covering in that at the moment. I think there is very close engagement between the GLA and the NHS and I think we have, hopefully, picked up on some of the Scrutinies, for example, working very closely with people who can help to inform, and make those as productive as possible. So, I just want to finish on that note but I hope I have brought home some of the key health issues in London but also the fact that it is most important for us to work in partnership with other agencies if we are going to address the inequalities across London. The things that really affect people s health are much broader than just the health services and it is important that we pick those up. There are a number of websites where there is much more information - I am happy to give those - but, certainly, the London Health Commission has a website; the Observatory has a website; and there are a number of reports and background information that might be relevant to members from those. The Chair: Thank you very much indeed. We are now going to move into our scrutiny session on what we ve just heard. Before we start our questioning, can I just remind the public that you can use the form on the last page of the agenda to send in any questions that you may want to ask Dr Sue Atkinson. Can I just start by asking why do think there are such differences in life expectancy across London boroughs and the difference has grown, I believe, throughout the 1990s? Dr Sue Atkinson (London Director of Public Health): They do relate very closely to the deprivation and poverty side of things. It is mostly the other factors, particularly on things like coronary heart disease and cancer. We know, for example, that although our best efforts at making the evidence around smoking, and how bad that is for your health, available generally, we know that over the past 20 years people in socioeconomic groups 1 and 2 have given up smoking but those in groups 4 and 5 have not. In fact, in some groups it has actually increased in those areas. Because smoking is such a big factor in coronary heart disease and in cancer, and those are the major killers, you will see a big effect with that and some of the deaths under 65, from coronary heart disease, are clearly linked very closely to smoking. That s why we want to focus on that so crucially. It s not just about telling people it s bad for you; it s also about enabling them to get the support they need to give up smoking. There is very clear evidence that at whatever stage you are, if you give up smoking, even if you are in your 40s or 50s, you will improve dramatically your life expectancy. It s worth giving up at any age, is the message, because it really, really makes a huge difference to those sort of factors. The Chair: When you talk about socioeconomic groups being 4 and 5, for people who perhaps don t understand that, who are you talking about? Dr Sue Atkinson (London Director of Public Health): It s very much people in unskilled jobs and unemployed people. Meg Hillier: You talk about a number of health determinants of which only a number are within the control of health services - that chart was quite interesting showing how little - and I wanted to know what are the areas of priority you think need to be tackled 14

15 in order to dramatically improve public health in London. Which other policy areas around environment and housing and so on? Dr Sue Atkinson (London Director of Public Health): One of the major ones is very much about focusing on maternal and child health. If we pick up young mothers in some of the programmes like Surestart and give them appropriate support, it is critically important. Education is critically important because there is such a clear line of connection, if you like, between people achieving at school, being able to get a decent job or going to university and being more healthy as a consequence of that. Those are the sort of issues that I think are critically important. On a specific note, things like good housing in terms of it not being damp and having adequate heating, is critically important to individuals and particularly to respiratory disease. It depends where you are. There may be different pockets of London where different things are more important but, overall, I think it is particularly the young mothers, and maternal and child health efforts. We know that if we address things there such as smoking in pregnancy, breastfeeding, support for parents, suitable support for children in the very young years, then those have a major difference on people s outcomes ultimately, and on the next generation. Meg Hillier: My next question is how you can influence that? One obvious example is the sale of hospital sites which often become luxury housing developments, sometimes with some affordable housing, sometimes not because, clearly, the Treasury is keen to get money into the Health Service, new hospitals need to be built and you can see the imperatives there, but there are enormous local imperatives for improving the housing stock in London. How do you feel, as the Director of Public Health in London, that you can influence that agenda and how do you think the GLA can work to influence it? Dr Sue Atkinson (London Director of Public Health): I think one of the things we ve been talking about recently, particularly with the London Plan and the expected increase in the population, is how do we make sure that the health aspects of urban planning and what needs to happen in those, are actually brought into account, and doing that comprehensively. We are just trying to work through, with the GLA, what s the best way that we can do that and also, for the Health Service, how can we get the best -- that is something that is new to some extent, the Health Service, so we need to think through it differently. We are trying to modernise the Health Service and that s not just about replicating the same sorts of wards and things, but actually thinking, What are the different ways we ought to be delivering services that would be addressing patients needs? That s thinking about primary care differently; it s thinking about walk-in clinics; it s thinking about ambulatory care, outpatient care, differently, etc. We need to look at that in the whole context of what s happening in this patch; what s available there already; what s the new population that s coming in; and can we influence those developments, whether they be housing or business or whatever developments, to make sure they are taking the health implications of what they are doing into account? That will be a whole plethora of things ranging from, is the building good to live in, has it got appropriate heating and is it environmentally sound, through to, are we making sure it s not built on one side of a road and putting a huge road through something that splits a community and stops all the social interaction, because of the importance of the social 15

16 interaction? It is quite a complex arena where we need, as the NHS, to be very closely tied in to the whole development agenda, the whole regeneration agenda and the developments that are happening in those patches. We are trying to work through what s the best way for us to do that. It is rather new to us so we are working our way through it. Meg Hillier: Does the London Plan achieve this? And how will you, as Director of Public Health, measure that achievement over the next 10, 15, 20 years? What targets and goals do you want to see reached? Dr Sue Atkinson (London Director of Public Health): I think some of the targets and goals are the ones that we may have already in the ten parameters we already selected for the Health Strategy. There is also some national work going on which I know the London Health Observatory is leading on behalf of the national observatories on it, to look at a basket of indicators on health inequalities. It will be particularly picking up those things. I think we may need to think about what are the specific parameters in relation to the London development that we need to pick up, and particularly for some of the specific areas, like the Thames Gateway, how would we measure what difference that is making? It s going to be very crucial. One of the things that came out of the Health Impact Assessment on the London Plan was that thinking about the communities who already live there, and what impact is it having on them and their health, is critically important. People are drawing analogies that we may not have done that as best as we could when the Docklands development happened. Can we learn from those lessons and take that into account when we re doing it differently? And so maintaining the populations that are there and not always thinking about regeneration as perhaps moving people out and other people in; it s got to be maintaining things for the populations there and improving their lot and therefore improving their health and wellbeing. Meg Hillier: With the Health Impact Assessment how will you be revisiting it because the Plan is an evolving thing? We have learned lessons from the past so how will you be making sure that in any reincarnations of the plan, those things are better addressed? Dr Sue Atkinson (London Director of Public Health): I think the proof of the pudding will be when the various Plans or Strategies are implemented. The Health Impact may have influenced what s written in the Plan, but are those actually implemented? I think we will be looking to the London Health Commission, who particularly keep an eye on that, that as those are implemented, are we making sure that the health implications are still being taken into account as they are implemented? Over and above that, I think one of the other things that struck us about the Health Impact Assessment is that we really need to be thinking whether we can pull together a health, economic, environment and social impact. Covering all four of those areas - economic, environment, social and health - because they all interrelate with each other so much. Is there a methodology we ought to be developing that puts those things together so that developers are not being asked, on the one hand, to do an environmental impact and then, on the other hand, being asked to do an economic impact and so on? We do a comprehensive package and that is built into the programme of developers putting forward their proposals. 16

17 Richard Barnes: Do you believe that the NHS structures and the partnerships which are slowly establishing are robust enough to improve Londoners health? Dr Sue Atkinson (London Director of Public Health): I think it s very early days with the current structures. As you know, we ve shifted to primary care trusts since April last year, and there are five strategic health authorities across London. The advantage of the primary care trusts is that they are all coterminous with boroughs and, as we have seen from what I ve talked about today, many of the things that are really important for people s health are in collaboration between what the local authorities have responsibility for and health, as well as other partners. That being the same geography, is a good starting point. We ve got a long way to go on developing those partnerships and we know that, if we look across London, there are some very good foundations for that in some boroughs and some PCTs working well together, building often on things like the Health Action Zones and so on. Whereas, in other areas, we ve got a long way to go in developing those relationships and the interfaces between those and other partners. I think it is early days. We have to let it bed down and take off. Clearly, PCTs are on a huge learning curve at the moment; they are only about six months into existence, many of them - a few of them were there beforehand - but on the whole they are moving ahead quite strongly. I m very pleased that there are Directors of Public Health in each of the PCTs. At the moment some of them are not very well supported and I think it is critical that we make sure that that capacity is there to do this joint working at a local level. Richard Barnes: I declare an interest; I m a member of a Strategic Health Authority, as you know. Health improvement programmes have been done at the borough and health authority level for quite some time. When do you think their impact will become visible or, indeed, the new structures will become visible? I have a number of fears and the fears are that 25%-30% of GPs will be retiring over the next 5-10 years. That will, I would have thought, have a major impact on Londoners access to primary care and, indeed, to health. Much of what we talk about here is a product of policies. We talk about London s health challenges. HIV and AIDS: if you look at the amount of money which is spent across the country, the vast concentration of it was within London and I know that people were drawn into London because of stigma, etc, so policies moved us here. Tuberculosis could well be allied to HIV and AIDS - again, you have a similar type structure - and it could also be related to the over-prescription of antibiotics over a number of years. There are challenges there which I m not quite sure we can impact because some of them will be lifestyle and some of them will be policy. Dr Sue Atkinson (London Director of Public Health): There are some factors in that. I m not sure about the over-prescription of antibiotics; that does have an effect on drug resistance - and we have some drug resistance in TB - but it s not a major issue in that respect apart from in those individual cases. 17

18 I think one of the critical things will be for the Strategic Health Authorities, whose main role is around performance management, to hold the primary care trusts to account for their partnership working and their working with local boroughs on some of these wider aspects. As you say, they are broader than sometimes the NHS can do itself. Clearly, where there are issues around population flows and population sizes, we are keen to make the case for getting adequate resources into London, and sometimes, as you say, some of those things are chickens and eggs. What you describe in HIV and AIDS, maybe there was a higher population in London and there probably is, because if you look at other sexually transmitted diseases there are higher records in London as well. But, clearly, there is also a pull into London; that may also be true of people with mental health problems, that those who are homeless or migrant do migrate into inner city areas. We know that that will happen and when we look at some of the comparisons to other cities across Europe and elsewhere, we also see those same patterns in capital cities. I don t know that we re going to change that. What we do need to be doing is make sure that we ve got the right policies and practices in place to try to address them with the appropriate resources. Richard Barnes: Do you have a target for how long I should live? Dr Sue Atkinson (London Director of Public Health): I think that s up to each of us to decide individually but probably most of us don t have much control over it. We have some control over it and, clearly, the average lifetime expectancy for men, at the moment, is around 78. That s what you expect but I expect you re in a higher socioeconomic group so I expect you to be well over 80. Richard Barnes: But it was ever thus that you ladies live longer than us. Dr Sue Atkinson (London Director of Public Health): Indeed, I am looking forward to 82 plus! Lynne Featherstone: I want to go into the data collection. When I look at the maps of London showing the boroughs that are going to survive longer than other boroughs, or the people in them, what I wanted to know was, with all of the ambitions and targets, goals and milestones, in an area of great deprivation if you apply a raft of policies across all the agencies, you would expect to see a change, a shift. In those areas that are not rated as deprived where there are pockets of deprivation which are untouched, how are you going to register those? The question I m coming on to is what milestones are you going to personally use to see if health equalities are changing? I m scared that it is not going to register for those areas that aren t in your main sight. Dr Sue Atkinson (London Director of Public Health): I think the point you make is a very good one. Some of the policies clearly focus on the 20 worst boroughs in the country, or whatever. There are often multiple inputs that go in there, some of the neighbourhood renewal areas, and so forth. But, in practice, when we look even within wards what we often see, even within wards, there are deprived bits. The challenge to individual PCTs and boroughs - although in some boroughs they may have a northsouth divide or something like that and they know they have to concentrate on this half of their borough and less so on the other half - historically, what s often happened is that resources have tended to go into the better half anyway. There are some areas 18

19 where we know that people may need to redress that balance which will not be a comfortable thing for people to do. The challenge also is for them to address where there are pockets of deprivation. Often where we see those, it is the same group of roads or families or whatever, that need multiple inputs and that is why it is critically important that the organisations on the ground, the service deliverers, work together so that we are seeing people from social services, people from education, people from health, all working together to address the particular issues of those individual families or groups of families. Lynne Featherstone: The question was: what milestones would you personally be looking for to see that you have succeeded? You have shown us ten indicators but what would be the priority and how would you get a register on that for those people who aren t in visible areas? Dr Sue Atkinson (London Director of Public Health): I think the other thing is about the basket of health inequalities indicators, and that clearly will be focused on trying to reduce the spread, if you like, of the ranges that we see. I think some of those same ten indicators will be in that. I think the other thing will be very much through the Strategic Health Authorities. Because they are covering one sector of London, they can concentrate on knowing that sector in quite a lot of detail and it will be down to them to say, What are you doing about inequalities in this patch or this patch? So, if you like, not letting the PCTs and the local authorities off the hook in terms of saying, We re only concentrating on this bit, but actually saying, Hang on, haven t you got other areas as well and what are the action plans in there? I think we also need to be shifting people s thinking from thinking about inputs, which is often what people do - I m going to put a programme of work that looks like this - to, What are the outcomes you expect from that? and getting people to define, themselves, what are their outcomes and, therefore, what are the markers that they expect to be seeing differently? Some of those will be about things like maintaining children in school who are currently truanting; maintaining good GCSE levels or improving those; they will be down to that sort of level. It s not something that obviously the Health Service can necessarily do alone; it has to do it in conjunction with the other bodies. 19