Annual Public Health Report 2010/11

Changes and Challenges...

Final version 1.0

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Contents

Introduction 3

Chapter 1: Changes and challenges... 6

Chapter 2: Inequalities 12

Chapter 3: Swimming upstream 21

Chapter 4: Obesity - more than an issue of fatness 40

Chapter 5: General Practice - a platform for more 49

Chapter 6: Putting the patient and community centre stage 68

Chapter 7: The power of information 77

Executive summary & recommendations 84

Appendix 1: Progress on the recommendations from last year’s

annual public health report 91

Acknowledgements 95

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Introduction

Annual public health reports are expected to provide an independent comment on the state of
health, and on local efforts to improve and protect health. They should also be written with a
critical eye and with the public interest in mind.

This year the report covers a number of high-level issues, rather than going deeply into one
particular issue. We wanted to produce a report that would provoke discussion about the broad
and ‘big picture’ challenges related to health and illness. In particular, this report responds to the
current context of major structural change and reform to the NHS; a large public deficit; and
forthcoming cuts to a number of health and local government services.

There are big and difficult challenges to overcome if the health of the population is to be
maintained and improved, and if unfair and avoidable inequalities in health are to be reduced.
Meeting these challenges will require a shared and coherent vision of health improvement
amongst a wide range of actors and stakeholders, and one aim of this report is to argue for the
creation of such a shared vision.

This report builds on four of the core attributes of ‘public health’:

• a whole population perspective - rather than one focused on individual patients and service
users;
• a ‘whole health systems’ perspective which includes hospitals, primary care, community
based care, and other health service elements;
• an emphasis on the prevention of illness and disease and the wider determinants of health;
• strong foundations in monitoring, research, evaluation and systematic review.

The outline of this report is as follows. The first chapter describes the major changes and
challenges facing both the local population and health system. It covers a number of policy-
related issues that are not specific to Hammersmith and Fulham (H&F) but which are nonetheless
important contextual factors.

The second chapter briefly describes the state of health inequalities in H&F. It is the causes,
pattern and degree of health inequality that should guide commissioning decisions and strategies,

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rather than the average or aggregate state of population health. For this reason, chapter three is
based on the Marmot Report on health inequalities in England that was published in 2010. We
look at the recommendations from this report and consider their application to H&F.

The fourth chapter is focused on a specific issue: child obesity. It is a serious but still neglected
health priority, and illustrates the importance of prevention. Having discussed a specific
population health issue, chapter five discusses a specific health systems topic: the General
Practice (GP) landscape of H&F. Health systems analysis is an important sub-discipline of public
health, and as GP practices are a critical foundation stone of the health system, we have provided
some data, analysis and discussion about them in this report.

This is followed by two chapters (6 and 7) designed to showcase elements of local public health
work. First, we describe the important work being done to engage with and empower patients and
local communities. Second, we provide some examples of the work being done to improve our
health information systems – a critical requirement for ensuring that we invest in the right services
and for ensuring that those services have the right impact. Going against convention, the report
ends with an executive summary, including key recommendations. Finally, there is an Appendix
which reports on the actions taken in response to last year’s annual public health report.

A requirement for a shared vision of health improvement is a shared understanding of the health
needs of the population. An adjunct to this report is therefore the Hammersmith and Fulham Joint
Strategic Needs Assessment (JSNA) which provides a repository of data, information and analysis
about the local health profile and local services (see box overleaf). JSNA documents can be found
online at www.hf-pct.nhs.uk/JSNA.

This is a fairly long report covering a wide range of issues. But still, it has many gaps and cannot
be considered a comprehensive report. We note in the report several areas that need future
attention and we hope these may be reflected in future outputs. These include: mental health; the
performance of hospitals and community services; school health; and health expenditure analysis.
However, I hope this report provides some new information and food for thought; and that it will
support debate and discussion!

Dr. David McCoy

Acting Director of Public Health

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 Box 1: JSNA Documents

2009/10

1. JSNA 200910 Executive summary

2. Demographic profile

3. Long-term condition data

4. Disease registers and co-morbidity

5. Mortality data

6. Hospitals admissions

7. JSNA 2009/10 core data set

2010

1. Children’s JSNA

2. Housing and Health

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Chapter 1: Changes and challenges

This year’s public health report is published in a context of change and turmoil.

• Primary Care Trusts (PCTs) will disappear and there will be a shrinkage of management
structures and systems. Since October 2010, the PCT has been going through a process of
downsizing and merger with Westminster and Kensington and Chelsea. Overall staff
numbers have been reduced by around 70 per cent.
• Responsibility and money will be handed over to new GP-led Consortia and a new NHS
Commissioning Board (NHSCB)
• The different parts of the NHS will be made more independent and free from public
control. All NHS trusts are expected to become or be part of a ‘foundation trust’ that will
have more freedom to act as independent entities.
• European competition law will apply to the NHS for the first time, shifting the health
system further in the direction of a competitive and market-based system.
• For the public health discipline, a new national public health service (Public Health
England) will be created and local public health functions will move from PCTs to local
government. There will also be a new ring-fenced budget for public health.
• Local government will be given further additional responsibilities for establishing Health
and Wellbeing Boards and Local Health Watches.
• Finally, placing patients at the centre of decision-making and giving them more choice
(including the information to exercise that choice) is given strong and new emphasis.

The hope is that these changes will liberate the NHS from excessive bureaucracy and top-
down management; promote greater clinical leadership; and move the NHS towards
becoming the “largest social enterprise sector in the world” in which competition and
innovation will flourish, and where the patient / consumer will drive up the standard of care
by exercising choice and voting with their feet.

These are big changes to the NHS. Some have called it the ‘biggest shake-up in decades’, and
there are many questioning the risks associated with such profound organisational change at a
time when the NHS faces huge financial constraints.

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Although the government has announced a very small rise in the NHS budget, in real terms
there will be shrinkage of NHS spending. Population growth, ageing and the high rate of
inflation associated with medical developments translate into pressure on budgets and ‘having
to do more with less’. In addition, some NHS funds will be ring-fenced to supplement adult
social care budgets. In Hammersmith and Fulham (H&F), deficits within the broader health
care economy have already resulted in cuts to some services and plans.

Costly medical and technological advancements don’t just mean that ‘more will have to be
done with less’; it could also mean that ‘more will be done for only some’. As the ability to
treat illness outstrips the public’s capacity to pay, the risk of unequal access to treatment
grows, threatening one of the founding principles of the NHS: to provide an equal service to
all on the basis of clinical need.

The financial challenges of the NHS will also need to be managed in the context of even more
severe reductions to other public budgets and services, including a number of local
government services that have a direct impact on health. Public sector job losses combined
with structural deficiencies in the economy will also mean increasing rates of unemployment
and household poverty, both of which are potent determinants of disease and illness, placing
further strain on the NHS.

Difficult decisions will need to be made about how best to make use of public money to
improve health, but even with all the research and evidence in the world, there is no single
‘correct answer’ to how resources should be used to maximise health - there are too many
trade-offs and value judgements involved. For example, what value or price do we place on
fairness, and how do we judge what is fair? How do we balance the emphasis between
protecting health for the future while responding to the immediate health needs of the sick in
the present? And what is the price worth paying for the extension of life compared to
improving the quality of life?

Health systems reforms and policies do not only impact on patients and the public; they also
impact on those working within the health system. Different ways of organising the health
system and different priorities result in income streams and benefits being distributed across
the health system in different ways. Hospital doctors, general practitioners, nurses,

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community pharmacists, midwives, health visitors, managers, community-based health
workers, third sector organisations, management consultants, drug companies and health
insurance companies – are all actors within the health system; but they operate in a zero-sum
game of finite resources, and each will have an incentive to compete for as big a share of the
pie as possible. Balancing the competing interests of different stakeholders within the health
system and with the competing needs of society is not straightforward.

There is also a need to consider the different purposes of the NHS. While it is mainly a
mechanism to respond to disease, illness and injury; it is also a number of other things. For
example, it is also a market and industry that generates business and returns on capital. It is
also a social and cultural institution that shapes society’s attitudes towards, and experience of,
ageing, illness, death and giving birth. And it can also influence the nature of society by
determining how and to what extent economic and social status influences access to health
and health care.

For these reasons, health systems policy should be a matter of public debate and
understanding, even more so given the economic climate and financial predicament of the
NHS. The government’s desire to stimulate a more engaged and active citizenry chimes with
this need, and places a challenge and duty on public health professionals to empower people
with the knowledge, information and capacities to participate in such discussions and debates.

So what’s to be said about the proposed changes for the NHS in H&F?

There is a lot to discuss and debate in terms of the proposed changes to the NHS, as well as
the policy, economic and demographic challenges described above. However, we highlight
two key messages from a PH perspective.

Whole systems planning, cooperation and coordination

Inpatient wards, outpatient clinics, GP practices, social care services, third sector
organisations, health visitors, community pharmacies, district nurses and ‘expert patients’ are
all different, but important components of a single health system. They need to be conjoined
to ensure efficiency and effectiveness, and to allow patients to experience a seamless journey

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through the health system. Health systems have been compared to an orchestra for this reason
- different parts of the health system need to collaborate and cooperate in the same way that
the different instruments of an orchestra need to be conducted to play the same music.

At a time of shrinking budgets and reduced management capacity, anything that moves the
NHS towards a more coordinated and efficient ‘whole systems approach’ will be a good
thing. For example, the past integration of the Primary Care Trust (PCT) and local
government under a single Chief Executive and the pooling of local government and NHS
funds led to many benefits, including a more integrated commissioning plan for community-
based adult and child services.

Although the PCT is no longer integrated with local government (partly due to the fact that
individual PCTs have had to merge to sustain cost reductions), the efforts of the past will
leave behind a legacy of partnership working across the health and social care divide that can
be built on.

There is also a need to ensure better integration within the NHS, particularly across hospitals,
GP practices and community health. Few things are as important as ensuring that primary and
secondary care services work in tandem to address the health priorities of the population.
Neither component of the health system works well without the other.

Although the White Paper provides no specific lever to ‘join up’ GP practices, community
health services and hospital services, it leaves room for local creativity and innovation.
Currently, there are proposals to develop a system of integrated care for diabetes and care of
the elderly involving Imperial Hospital, GPs, the community health services provided by
Central London Community Health (CLCH) and the local council – a significant development
that could pave the way for more effective and efficient whole systems management.

However, the need for better coordination and strategic planning across the health system, and
the wish to encourage greater choice and competition creates a tension. While a more
commercial and competitive approach to health care delivery offers the opportunity for
entrepreneurialism, dynamism and innovation, it carries the threat of greater fragmentation,
inefficiency (for example through excessive income generation and the costs of market

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coordination and regulation) and the undermining of collaboration and cooperation.

Writing recently in the BMJ, one prominent GP commentator wrote of the tension between
competition and cooperation: “If the delivery of health care could once again be made a
cooperative and collaborative endeavour, the benefits in terms of morale, enthusiasm, and
renewed altruism could be enormous. Difficult debates lie ahead concerning the increasing
costs of medical technology, the medicalisation of an ever greater proportion of human
experience, the increasing futility and even cruelty of inappropriate and ineffective treatments
at the end of life, and the optimal balance between curative and preventive health care. None
of these can be solved by competition. Only broad public debate and a politics of consensus
offer real hope for the continuation of a humane, inclusive, and affordable health service” 1

This quote not only raises the importance of cooperation amongst different service providers
for individual providers; it also highlights its importance from a policy perspective and
suggests that a culture of cooperation can be an important determinant of the ethical culture
and standards of a health service. Clearly, rigid and monolithic health systems contain their
own weaknesses and dangers. The critical point is that the forthcoming period of change and
reorganisation must be accompanied by a constant questioning of whether we have the
culture, instincts and set of incentives to avoid unhealthy competition and non-collaboration
within the health system.

Population-wide assessments of health, need and service provision will also become ever
more important, as well as open debate and discussion about priorities. The emphasis placed
on Joint Strategic Needs Assessments (JSNAs) and the proposed establishment of Health and
Wellbeing Boards offer an opportunity for better integration, cooperation and collaboration
amongst providers and commissioners alike.

Prevention

The second key message is that we have to place a greater emphasis on the prevention of ill
health. Maintaining and improving health in the context of an ageing population, rising

1
Heath I, 2010. The costs of the reverberating bedpan. BMJ 2010; 341:c5541 doi: 10.1136/bmj.c5541

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medical costs, shrinking NHS resources and major local government cuts requires the health
system to improve its ability to prevent illness, disease and injury, and to shift the NHS
towards being more of a national health service and less of a national sickness service.

The health system needs to get better at preventing illness, disease and injury (primary
prevention); and reducing the severity and impacts of illnesses and diseases (secondary
prevention). According to the White Paper on Public Health (Healthy Lives, Healthy People),
changing adults’ behaviour could reduce premature death, illness and costs to society,
avoiding a substantial proportion of cancers, vascular dementias, and over 30% of
circulatory diseases: saving the NHS the £2.7 billion cost of alcohol abuse; and saving
society the £13.9 billion a year spent on tackling drug-fuelled crime.

Every contact with a patient should be an opportunity for clinicians to promote health, and
prevent illness. This should mean that hospitals which focus on the treatment of illness should
also be seen as a point of care where preventative services are provided. Health professionals
must also advocate for the social, economic and environmental pre-conditions of good health;
and consider how NHS resources can optimise health through non-NHS actors and non-
clinical interventions.

Historically, the NHS has performed poorly in terms of prevention. According to Healthy
Lives, Healthy People, “prevention has not enjoyed parity with NHS treatment and that
public health funds have too often been raided by acute and clinical services”. One of the
welcome innovations of the new government is that there will be ring-fenced public health
spending, from within the overall NHS budget, to support some of the prevention agenda
(although it remains to be seen whether or not the size of the ring-fenced budget will be
sufficient).

By placing public health resources in local government there is an opportunity to strengthen

the NHS’s role in tackling the upstream and social determinants of ill health. This is an issue
that is discussed in chapter 3, but before that, chapter 2 presents and discusses the health
inequalities challenge.

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Chapter 2: Inequalities

Many health inequalities are normal and expected. Perfect health equality is impossible. For a
start, we are all born with a different genetic disposition to disease and illness; we also know
that some conditions are sex-linked, making perfect gender equality in health an impossibility.

However, a significant amount of existing health inequalities are unfair and avoidable. This is
sometimes referred to as health inequities. Furthermore, inequalities in health have been
growing in spite of explicit policies and plans to reduce them. The current economic and
fiscal situation has every prospect of worsening health inequalities still further.

Clearly, there are moral and ethical reasons to eliminate those causes of health inequality that
are unfair and avoidable. But there are also economic and pragmatic reasons. The cost of
improving health amongst those with poor health would, in many instances, be more cost-
effective than improving the health of those who are already relatively healthy.

Sickness and premature mortality amongst those with poor health is also expensive.
Inequality in illness is estimated to account for productivity losses of £31-33 billion per year,
lost taxes and higher welfare payments in the range of £20-32 billion per year, and additional
NHS healthcare costs in excess of £5.5 billion per year. 2 If no action is taken, the cost of
treating the various illnesses that result from inequalities in the level of obesity alone, is
estimated to rise from £2 billion per year to nearly £5 billion per year in 2025. 3

In 2009, a high-profile and extensive study on the avoidable causes of health inequalities and
the prevailing policy response to this issue was published: the Marmot Review on Health
Inequalities. 4 We summarise the key findings of this report and examine their relevance in
chapter three, but first, a few facts about health inequality in Hammersmith and Fulham.

2
Frontier Economics (2009) Overall costs of health inequalities. Submission to the Marmot Review.
www.ucl.ac.uk/gheg/marmotreview/Documents.
3
McPherson K and Brown M (2009) Social class and obesity - effects on disease and health service treatment costs.
Submission to the Marmot Review. - www.ucl.ac.uk/gheg/marmotreview/Documents
4
Marmot Review. Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England post-2010.

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Unequal Life Expectancy in Hammersmith and Fulham

Inequalities in health are commonly described in terms of life expectancy variations. For
example, in Hammersmith and Fulham, there is a 7.1 year gap in male life expectancy and a
11.7 year gap in female life expectancy between people living in different wards in the
borough (see below).

Male Life Expectancy at Ward Level: 2003/07 (Source: London Health Observatory)

Female Life Expectancy at Ward Level: 2003/07 (Source: London Health Observatory)

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Interestingly, the fact that females in Hammersmith and Fulham have a larger gap in life
expectancy across wards than males is not reflected across London, where male life
expectancy ranges from 88 years in a ward in Kensington and Chelsea to 71 years in
Lewisham Central (a gap of 17 years) and female life expectancy ranges from 76 years in a
ward in Newham to 90 years in Knightsbridge (a gap of 14 years).

Although average life expectancy has risen in H&F, the gap between the poorer and richer
segments of the population has grown, increasing from 6.1 years in 2001/05 to 9.1 years in
2004/08 for men, and from 2.3 years in 2001/05 to 4 years in 2004/08 for women. The two
graphs below show the trends in life expectancy for men and women comparing people in the
bottom and top tenth of the socio-economic spectrum.

Trend in Male Life Expectancy in Hammersmith & Fulham (Source: APHO)

Trend in Female Life Expectancy in Hammersmith & Fulham (Source: APHO)

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Premature mortality

Underlying the gap in life expectancy is the fact that some men and women, especially those
from lower socio-economic status groups, die early. It is therefore worth looking at the causes
of premature deaths.

In Hammersmith and Fulham, between 2006 and 2008, there were 643 deaths occurring to
adults below the age of 65 years - 414 men (64%) and 229 (36%) women. This translates into
a premature mortality rate of 231 deaths per 100,000 population per year which is above the
London average. Two of the borough’s six statistical neighbours 5 (Tower Hamlets and
Islington) have significantly higher premature mortality rates. If Hammersmith and Fulham
had the same premature mortality rate as Kensington and Chelsea (which has one of the
lowest rates of premature mortality), there would be approx. 50 fewer premature deaths a year
in actual numbers.

Directly standardised rate per 100,000 of premature mortality from all causes, ages 15-
64, 2006-08 (Source: NCHOD)

5
ONS Cluster: Camden, Hammersmith and Fulham, Islington, Kensington and Chelsea, Wandsworth, Westminster and
Tower Hamlets.

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Within H&F, as one would expect, deprived residents have a significantly higher premature
mortality rate compared to the least deprived residents as shown in the figure below.

Crude rate per 100,000 of premature mortality from all causes by local deprivation
quintiles, ages 15-64, 2006-08 (Source: ONS Mortality Files)

The main causes of premature mortality are: cancers (mainly bowel, lung and breast cancers),
circulatory disease and diseases of the digestive system (mainly liver disease). These three
sets of diseases make up about two thirds of all premature deaths. Both breast and bowel
cancers are now the target of early detection screening programmes; and the risk for all of
these diseases is increased by smoking and unhealthy levels of alcohol consumption.

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 Percentage of premature deaths by underlying cause: 2006-08
(Source: ONS Mortality Files)

While the early detection of disease and quick access to medical care can help prolong life
and reduce mortality, social, behavioural and environmental factors that determine
vulnerability and susceptibility to these diseases are what primarily determine the overall
pattern of premature mortality and health inequalities across society.

Dying younger and suffering longer

Differences in life expectancy and premature mortality rates do not fully describe inequalities
in health because they do not capture the severity and length of illness and disability prior to
death. However, when health status is measured as a product of both longevity and quality of
life, the disparity between the rich and poor is much greater.

For example, across England as a whole, although people in the poorest neighbourhoods die
on average 7 years earlier than people in the richest neighbourhoods, the difference in
disability free life expectancy 6 is 17 years. This means that not only do poor people generally

6
Disability-free life expectancy is the average number of years an individual is expected to live free of disability if current
patterns of mortality and disability continue to apply.

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die earlier than their richer counterparts, but they live with sickness, illness and disability for
a much greater proportion of their life.

In Hammersmith and Fulham the gap in terms of disability free life expectancy between the
most deprived area and least deprived area has been estimated to be 9.6 years for males and
12.3 years for females. Across London, the gaps in disability free life expectancy are higher:
between the most deprived small area (in Newham) and the least deprived area (in Bromley),
it is 19.5 years for males and 15.5 years for females 7.

Children are not exempt

While inequalities in adult health may provoke equivocal reactions, a decent society would
find systemic, unfair and avoidable inequalities in child health to be unacceptable. The reality
is that children demonstrate marked inequalities in their state of health.

The Income Deprivation Affecting Children Index (IDACI) is a measure of the percentage of
children (under 16) who live in income-deprived families (i.e. in receipt of Income Support,
Income based Jobseeker's Allowance, Working Families' Tax Credit or Disabled Person's Tax
Credit below a given threshold). The index scores range from 0 (least deprived) to 0.99 (most
deprived) and every lower super output area (LSOA) in England has been ranked from 1
(most deprived) to 32,482 (least deprived).

Scores in Hammersmith & Fulham range from 0.77 (Rank - 155) in the most deprived LSOA
in the North End ward of the borough to 0.04 (Rank - 28,709) in the least deprived LSOA in
Ravenscourt Park ward. The average IDACI score for H&F is 0.36, indicating a high number
of children living in families that are income deprived.

Additionally, the Child Well-being Index (CWI) covers the major domains of a child’s life
that have an impact on his or her well-being. The seven domains are: material well-being,
health, education, crime, housing, environment and children in need. By this index, H&F is
the 23rd most deprived out of 354 local authorities in England. The relevance of this data is

7
ONS experimental stats 1999-2003. Available at http://www.statistics.gov.uk/CCI/article.asp?ID=2562

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that there is a strong causal relationship between poverty (both in absolute and relative terms)
and social deprivation with poor health. This is discussed more in Chapter three. But, what
follows now, is a brief description of the state of health inequalities amongst children in H&F.

In H&F, there are about eight child deaths every year. With such small numbers, it is not
possible to conduct any statistical analyses of differential rates of infant mortality within the
borough. However, across England, where we can analyse much bigger numbers of child
deaths, infant mortality rates vary. For example, Pakistani and Black Caribbean babies are
twice as likely to die in their first year (9.8 and 9.6 deaths per 1,000 live births, respectively)
compared to White British or Bangladeshi babies (4.5 per 1000 and 4.2 per 1000
respectively).

Within H&F, we need to look at other indicators to reveal the existence of child health
inequalities. For example, low birth weight babies (<2500 grams) begin their lives at a greater
risk of illness compared to babies of normal birthweight. In H&F about 7% of babies born are
low birthweight, amounting to around 190 babies per year. The percentage of babies born
with a low birthweight is significantly higher in the most deprived areas compared to the least
deprived areas. If the low birthweight rate in the most deprived areas (8.1%) was reduced to
that of the least deprived areas (4.9%), an estimated 21 fewer babies would be born with low
birthweight in the borough each year.

A further illustration of child health inequalities is the difference in rates of 5 year old
children with at least one decayed, missing or filled tooth (DMFT). This is a marker of poor
dental health, which in turn is a marker of poor nutrition as well as poor child care.
Hammersmith and Fulham has one of the highest rates of children with poor dental health,
with an average of 1.91 DMFT per child. In one survey of two hundred 5 year olds, it was
found that nearly half of all children (44.5%) had a DMFT with an average of 4.1 teeth
affected.

Finally, we can also see health inequalities in the pattern of childhood obesity in
Hammersmith and Fulham, where about 12% of children in reception (age 4-5) and about
23% in year 6 (age 10-11) are obese. Deprivation is a clear factor in the pattern of obesity.
When child weights are analysed according to the ‘Income Deprivation Affecting Children

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Index’ (IDACI), a clear gradient is seen with obesity being statistically more common among
children living in deprived areas. Ethnicity is also a factor. Children of ‘white’ ethnicity have
a lower prevalence compared to children in ‘other ethnic groups.’ In chapter four, we discuss
the issue of child obesity in more detail, but before that, chapter three will discuss the
challenge of tackling the upstream determinants of health which are necessary if real and
sustainable progress is to be made in reducing health inequalities.

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Chapter 3: Swimming upstream
Health inequalities are mainly a by-product of social and economic inequalities. In the words
of the Marmot Report 8, health inequalities “stem from avoidable inequalities in society: of
income, education, employment and neighbourhood circumstances”.

The report goes on to state that “serious health inequalities do not arise by chance, and they
cannot be attributed simply to genetic make-up, ‘bad’, unhealthy behaviour, or difficulties in
access to medical care, important as those factors may be. Social and economic differences in
health status reflect, and are caused by, social and economic inequalities in society”.

While there is a degree of reverse causality - people with poor health are more likely to suffer
socio-economically - the overwhelming evidence points to a range of social determinants
having a profound impact on the pattern of health and wellbeing in society. This led Marmot
to conclude that “a debate about how to close the health gap has to be a debate about what
sort of society people want”.

Thus, among the recommendations was a call for society to move beyond economic growth as
the primary measure of progress and development, and for well-being to be a more important
societal goal. Instead of health improvement being commonly viewed as a downstream
consequence of economic growth, the challenge would be to view economic policy as an
instrument that would be subservient to meeting social goals.

The Marmot Report also draws the line between health, economic growth and environmental
sustainability. Because of the real and present threat of ecological collapse, we need to also
rethink our concepts of human progress and development. Importantly, the report argues that
a sustainable future is compatible with action to reduce health inequalities. For example, it
notes how “sustainable local communities, active transport, sustainable food production, and
zero-carbon houses will have health benefits across society”.

8
The Marmot Report is the outcome of a commission established by the Secretary of State for Health in 2008. It was
chaired by Professor Sir Michael Marmot and given four tasks: First, to identify the health inequalities challenge facing
England, and the evidence most relevant to underpinning future policy and action; second, to show how this evidence could
be translated into practice; third, to advise on possible objectives and measures; and fourth, to publish a report of the
Review’s work that would contribute to the development of a post-2010 health inequalities strategy.

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Venturing further into the field of economic policy, the Marmot Report also warned that
“simply restoring economic growth, trying to return to the status quo, while cutting public
spending, should not be an option. Economic growth without reducing relative inequality will
not reduce health inequalities. The economic growth of the last 30 years has not narrowed
income inequalities”.

Two other messages are worth highlighting.

First, the social gradient in health is seen right across the spectrum. This implies that focusing
solely on the most disadvantaged will have a limited impact on health inequalities. To reduce
the steepness of the social gradient in health, actions must be universal, but with a scale and
intensity that is proportionate to the level of disadvantage. Marmot and his team call this the
principle of proportionate universalism.

Second, there is strong evidence that the degree of social inequality is an independent
determinant of levels of average health. In other words, the worse the social inequality, the
worse the overall level of health for any given society. More unequal societies have more
unequal health outcomes and poorer average health outcomes. Furthermore, this relationship
doesn’t just hold true for health; it holds true for a range of other social outcomes including
rates of homicide, drug addiction and imprisonment.

The reason for this is that relative levels of social and economic status provoke significant
physiological and psychological reactions that can in turn negatively influence our behaviour
and bodies. The evidence and arguments summarised here have been expertly presented in a
book by Richard Wilkinson and Kate Pickett called the Spirit Level.

Can the trend of rising inequalities be reversed?

Yes it can; but not by the NHS on its own. Clinical and NHS-led interventions can only do so
much. The role of medical care is important, but limited.

While reducing inequalities in access to clinical care and preventative medicine (e.g.
screening services and immunisations) will help reduce health inequalities, it will not change

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the social gaps that underpin health inequalities. To reduce health inequalities and maintain
health improvement, especially in the face of the present economic and financial challenges,
we need to swim upstream.

Swimming upstream

If health inequalities are largely an outcome of social and economic inequalities, it goes
without saying that their reduction requires social and economic interventions. The Marmot
report made a set of recommendations organised around six broad policy areas:

• Give every child the best start in life

• Enable all children, young people and adults to maximise their capabilities and have
control over their lives
• Create fair employment and good work for all
• Ensure healthy standard of living for all
• Create and develop healthy and sustainable places and communities
• Strengthen the role and impact of ill health prevention

Their recommendations were also underpinned by two policy mechanisms:

• Considering equality and health equity in all policies, across the whole of government,
not just the health sector
• Effective evidence-based interventions and delivery systems.

Importantly, the report emphasised that delivering these policy objectives would require
action by central and local government, the NHS, the third and private sectors and community
groups. A particularly strong emphasis was placed on local delivery systems and local
government. According to the report, “national policies will not work without effective local
delivery systems” which in turn requires “effective participatory decision-making at local
level”, which in turn “can only happen by empowering individuals and local communities”.

The next section examines the key recommendations of the Marmot Report, and places them
in the context of Hammersmith and Fulham.

23
Key policy recommendations from the Marmot Report

A. Give every child the best start in life

The first policy area highlighted by the Marmot Report concerns early childhood
development, care and nutrition. According to the Report, “the foundations for virtually every
aspect of human development - physical, intellectual and emotional - are laid in early
childhood. What happens during these early years (starting in the womb) has lifelong effects
on many aspects of health and well-being - from obesity, heart disease and mental health, to
educational achievement and economic status”.

This implies a need to ensure positive early experiences for children. Interventions later in
life, although important, are considerably less effective where good early foundations are
lacking. The importance of this recommendation for H&F cannot be over-stated given the
high number of children living in income-deprived and stressed families, as well as, the high
rate of dental caries and obesity, both of which are indicators of poor early experiences
amongst a large number of children.

Efforts to improve early childhood development need to begin in pregnancy with the
provision of good antenatal care. But it is not just the provision of clinical care that is
important. Equally important is adequate social, emotional and practical support for pregnant
women and their partners. The primary source of such support is from within families and
communities, but public services can also be important (e.g. providing information about
child care and nutrition; supporting pregnant women to stop smoking; and helping women
and couples in need with social and psychological support).

In H&F, maternity services are provided by two main acute hospitals (Imperial College NHS
Healthcare Trust and Chelsea and Westminster NHS Foundation Trust) and are commissioned
by the North West London Commissioning Partnership. Investments have been made in
recent years to increase midwifery staffing levels; improve choice of access to services and
place of delivery; and ensure the early uptake of antenatal care. To improve the continuity of
care from pregnancy, labour to the post natal period, there have been efforts to improve the
liaison between midwives (employed by hospitals) and health visitors (employed by CLCH).

24
Another key intervention is the Family Nurse Partnership programme which is a dedicated
nurse-led service for pregnant teenagers and other vulnerable first time mothers, designed to
realise the benefits of early intervention during pregnancy and the first two years of the
child’s life. In H&F it comprises three Family Nurses and some additional psychology input.

The Health Visitor service in H&F is currently constrained by a general shortage of Health
Visitors (HVs) in London. The new government has partially recognised the importance of
HVs by announcing that an extra 4,200 HVs will be trained by 2014-15. In H&F, the Health
Visitor service is incorporated into a broader Healthy Child Programme for children aged 0-5
years. At present, a multi-disciplinary team of about 20 health visitors, health visitor
assistants, childcare advisors, community nurses and administrative support provide a family
focused health promotion and parenting support programme in partnership with children’s
centres, GPs and other agencies. In order to facilitate this inter-agency and holistic approach,
the programme is organised according to six geographical clusters with named leads
designated to individual GP practices and children’s centres. There is also a community-based
child nursing service provided by CLCH which is targeted mainly at providing support and
care to children with long term conditions and disabilities.

Among the aims of the Healthy Child Programme are to improve child health outcomes
through a reduction in smoking; promoting a continuation of breast feeding; improvement in
diet and nutrition; positive parenting and family relationships; increased immunisation rates;
lower frequency of accidents; improved dental health; reduction in child abuse and neglect;
improved language and social development, and improved readiness for school. In addition,
the programme aims to improve positive parenting and family relationships and the increased
involvement of fathers.

There are currently 15 children’s centres (including designated sure start centres) which offer
a range of services to all families from pregnancy until children start at school. The idea of
children’s centres is to provide a holistic service and support mechanism for families and
carers of young children provided by close and integrated working between health, education
and social care professionals.

In addition to a range of universal and drop-in services, children’s centres also provide

25
support to vulnerable children and families with particular needs (e.g. those experiencing
domestic violence or mothers with post-natal depression).

The nexus of services and facilities described above provide the basic foundation for
delivering one of the most important public health priorities: positive early child experiences.
However, the effectiveness of these services depends on three critical requirements.

First, effective inter-disciplinary cooperation and teamwork, especially between midwives,

health visitors, social care providers, educational and developmental psychologists, and other
services delivered through children’s centres. As these professionals work in different
organisations, good inter-organisational cooperation and teamwork is essential.

Second, for different disciplines and organisations to work together, an effective system is
required – this includes effective and efficient protocols for communication, referrals and
sharing information; the organisation of different staff into area-based teams (ideally clustered
around children’s centres); and, an appropriate prioritisation and allocation of case loads.

Third, the quality of service provided needs to be good and to employ effective evidence
based interventions. While there are a number of performance-related indicators such as
measuring the number of contacts, visits and services provided, there is also a need to assess
the quality and impact of those services.

B. Enable all children, young people and adults to maximise their capabilities and
have control over their lives

The Marmot Report’s second policy area highlights the need to maximise the capabilities of
children, young people and adolescents. Education receives special attention, based on the
evidence that educational outcomes impact profoundly on physical and mental health, as well
as future income, employment and quality of life. Central to this is the acquisition of both
cognitive and non-cognitive skills.

The performance of schools in Hammersmith and Fulham is generally good. For example, the
percentage of students achieving 2 or more passes at A Level (or equivalent) in 2009 was

26
96.6% compared to a London average of 94.8%; and the percentage of students achieving 5+
passes (grades A*-C) at KS4 (GCSE or equivalent) including English and Mathematics was
64.1% compared to a London average of 53.9% 9.

These are impressive indicators. However, it should be noted that schools in H&F include a
large number of children who come from outside the borough. In addition, we have to bear in
mind the fact that exam-based indicators, while important in their own right, do not provide a
sensitive marker of overall educational and developmental outcomes.

Predictably, there are variations in the exam performance of pupils within the borough. For
example, children who were in receipt of Free School Meals performed on average 17.3%
worse than the borough average in achieving 5 or more A* to C grades at KS4 (including
English and Mathematics).

% of Students achieving 5+ passes at KS4 (GCSE or equivalent) including English and

Mathematics in 2009 by their Free School Meals status
(Source: London Borough of Hammersmith & Fulham)

Pupils achieving 5+ A* to C
including English and Mathematics
GCSE

% Difference
Total from Borough
Pupils Number % average

No Free School Meals 723 520 71.9 7.9

Eligible for Free School Meals 329 154 46.8 -17.3

Additionally, in 2009 there was also wide variation in GCSE attainment by ethnicity in the
borough. The table below shows that children from a ‘White’ background generally perform
above average in comparison to the rest of the borough, while the stark difference between the
borough average and the attainment of children from a ‘Black Caribbean’ or mixed ‘White /
Black Caribbean’ background is particularly significant.

9
Department for Education 2009. Data available online at
http://www.education.gov.uk/inyourarea/statics/wards_lea_205_1.shtml

27
 % of Students achieving 5+ passes at KS4 (GCSE or equivalent) including English and
Mathematics in 2009 by Ethnicity (Source: London Borough of Hammersmith & Fulham)

Pupils achieving 5+ A* to C including

English and Mathematics GCSE

% Difference
Total from Borough
Pupils Number % average

Any Other Asian Background 36 27 75.0 10.9

Any Other Black Background 25 12 48.0 -16.1
Any Other Ethnic Group 101 63 62.4 -1.7
Any Other Mixed Background 31 18 58.1 -6.0
Bangladeshi 23 12 52.2 -11.9
Black African 134 87 64.9 0.9
Black Caribbean 89 37 41.6 -22.5
Chinese ~ ~ ~ ~
Indian ~ ~ ~ ~
Pakistani 13 9 69.2 5.2
White British 344 242 70.3 6.3
White Roma ~ ~ ~ ~
White Irish 33 28 84.8 20.8
White Other 102 75 73.5 9.5
White / Asian 12 11 91.7 27.6
White / Black African 9 3 33.3 -30.7
White / Black Caribbean 47 16 34.0 -30.0

Improving educational performance and reducing educational inequalities is clearly a

challenge for education policy and schools. However, of relevance from a health perspective
is the relationship between social determinants such as family background, peer relationships
and neighbourhood characteristics with educational outcomes. Some evidence noted in the
Marmot Report suggests that the most important factor influencing educational outcome is the
family. In this way, social care and family support is an intervention that improves both health
and educational outcomes.

In H&F, work is being undertaken mainly by the council to develop a more effective and
integrated service targeted at families in need of support. The emphasis is presently on those
families that are particularly “chaotic” and consume a disproportionate amount of public
services. There is a financial need to do this. But as this challenge is addressed, there will

28
need to be a gradual shift towards an approach that also prioritises those families that may not
necessarily be high consumers of public finance but which nonetheless constitute a high risk
environment for the social and educational development of young children.

Phoenix School in White City exemplifies the potential approach that can be undertaken by
schools to improve educational, social and health in a holistic manner. It currently stands at
the top of the Government's exam league tables for improved performance. In addition to this,
as noted in a recent Ofsted report, "The Phoenix is a remarkable school: it continues to
transform the life chances of both students and their families" because it has "a deeply rooted
understanding and heartfelt appreciation" of the challenging circumstances faced by its pupils.

It therefore embodies one of the recommendations of the Marmot Report, which is that
schools should take a ‘whole child’ approach to education and development, which includes
implementing ‘full service’ extended school approaches, and enabling the school-based
workforce to work across school–home boundaries.

In Phoenix, this has been achieved in spite of considerable challenges. More than half of the
school's pupils take advantage of free school meals, and 60% are on the register for those with
special needs. Its pupil mobility rate - the total movement in and out of the school by pupils
other than at the usual times of joining and leaving - is between 25 and 30 per cent due to the
number of children forced to leave every year because they are being re-housed or because of
relationship breakdowns. Pupils at the school also speak 50 different first languages.

The school works in partnership with a range of other actors including the PCT, third sector
organisations and community groups. The police have also initiated a range of additional
initiatives aimed at developing the school as a hub for social and community development.
These include initiatives centred on sports and leisure; farming and diet; and climate change.
Engagement with families and communities is strong and facilitated by, amongst other things,
the existence of a dedicated family liaison post.

The Marmot report also emphasises the importance of quality lifelong learning opportunities
across the social gradient, by calling for the greater provision of advice for 16–25 year olds on
life skills, training and employment opportunities; of work-based learning, including

29
apprenticeships, for young people and those changing jobs/careers; and increasing availability
of non-vocational lifelong learning across the life course.

C. Create fair employment and good work for all

The third policy area concerns employment. It is well known that unemployment has a hugely
detrimental impact on health. The high rates of unemployment experienced in the early 1980s
provide stark evidence of this fact: the figure below shows the social gradient in the
subsequent mortality of those that experienced unemployment in the early 1980s.

Mortality of men in England and Wales in 1981-92, by social class and employment
status at the 1981 census (Source: Office for National Statistics)

Insecure and poor quality employment is also associated with increased risks of poor physical
and mental health. In the words of the Marmot Report, “jobs need to offer a minimum level of
quality, a decent living wage, opportunities for in-work development, the flexibility to enable
people to balance work and family life, and protection from adverse working conditions that
can damage health”. There is a relationship between a person’s status at work and how much
control and support they have there. These factors, in turn, have biological effects and are
related to increased risk of ill-health.

30
We know that patterns of employment both reflect and reinforce social inequalities and that
there are inequities within the labour market. We know that rates of unemployment are
highest among those with no or few qualifications and skills, people with disabilities, those
with caring responsibilities, those from some ethnic minority groups, older workers and, in
particular, young people, and when in work, “these same groups are more likely to be in low-
paid, poor quality jobs; many are trapped in a cycle of low-paid, poor quality work and
unemployment”.

The relationship between employment / work and health is set to become more important over
the next few years. Some experts currently predict the loss of half a million public sector jobs,
as well as job losses in the private sector across the country. The graph below shows that
current unemployment rates in the UK are settling around 8% (approx. 2.45 million people),
after over a 2% increase between 2008 and 2009. Unemployment rates are currently the
highest they have been for a decade and expectations are that they will continue to rise in the
short term.

Percentage Unemployment (persons aged 16-64) across the United Kingdom 1999-2010
(Source: Office for National Statistics)

31
Locally, it is estimated that unemployment stands at 9.2% of the economically active
population in Hammersmith & Fulham (ONS, June 2010). This marks an upward trend over
recent years.

Percentage of economically active persons (aged 16-64) unemployed in Hammersmith &

Fulham 2004-10 (Source: Office for National Statistics)

We also know that 3.9% of the economically active population claim Jobseekers Allowance
(July 2010), of which 20.6% of all claims are made by young adults aged 18-24 (5.0% of the
total population aged 16 to 24 in the borough). The southern wards of Palace Riverside,
Munster, and Parsons Green & Walham have the three lowest claimant rates in the borough
(at 1.4%, 2.2% and 2.3% respectively). The northern wards of Wormholt & White City, and
College Park & Old Oak have the two highest JSA claimant rates in the borough (at 6.3% and
5.5% respectively).

It is difficult to identify actions that can be taken at the local level to increase employment.
Local (and national) economies are today much more heavily integrated into a global
economic system which is largely driven by the imperatives of financial capital rather than
social need. High, middle and low income countries are all experiencing the spectre of large
segments of their population in permanent or insecure and low-paid employment. The current
reduction of the public sector workforce is designed in theory to help stimulate economic

32
recovery through the private sector; but it remains hard to see how new jobs and opportunities
will be created to avoid further rises in unemployment and worklessness.

Hammersmith and Fulham has an economic development strategy which was published in
August 2007, and which includes a section on job creation. However, this was developed
prior to the financial turmoil and economic downturn; and requires a review and revision,
including the development of strategies such as ‘active labour schemes’ which were promoted
by the Marmot Report.

This is something that the NHS itself could promote. The NHS is a great employer - as it
should be: health workers and carers form the lifeblood of any health system. As the country
moves into uncertain and worrying social and economic waters, the NHS could look at how
the health system can act, not just as a means of improving health directly, but also as a means
of improving health indirectly through its potential to maximise meaningful and socially
useful employment. In addition, the NHS provides a huge terrain within which it can offer
training or voluntary work opportunities - while not a solution to chronic unemployment, such
opportunities could nonetheless have substantial positive impacts on health and wellbeing.

There has been little evidence generated to examine how the health system can mitigate the
negative effects of unemployment. Up to now, the focus of research has been to describe the
association between unemployment and health, but with little assessment of how healthcare
interventions could prevent or reduce the negative impacts of unemployment.

For example, exploring the role of GPs and the primary care system. In Sydney, Australia,
standards have been developed for the primary care management of the health problems of
unemployed people. 10 GPs trained in these standards were found to have gained confidence in
managing the problems of their unemployed patients, increased their knowledge of local
services, and disabused themselves of a number of prejudices about unemployed people.

Of importance is the notion of anticipatory care. Rather than wait for individuals to enter into
a spiral of despair and stress which then leads to depression, alcoholism and domestic

10
Harris E, Webster IW, Harris MF and Lee PJ Unemployment and health: the healthcare system's role Medical Journal of
Australia, 1998; 168: 291-296.

33
violence, the primary care system should intervene earlier. It is easier and cheaper to
intervene early rather than to wait until health problems become more manifest and severe.
Better communication and collaboration between local service providers might enable us to
identify individuals who have recently been made unemployed, assess their vulnerability and
then implement a more pro-active set of interventions to support high risk individuals and
families before chronic and intractable problems set in. There is also evidence that short
courses / interventions to improve problem-solving skills and reduce negative feelings and
beliefs have positive and long-lasting impacts on health and future work prospects.

D. Ensure a healthy standard of living for all

The fourth policy area of the Marmot Report will only be briefly mentioned here as it relates
mostly to areas of national policy. It draws attention to the issue of poverty and living
standards. Being poor is a significant determinant of ill health. According to the Marmot
Report, there are gaps between a minimum income for healthy living and the level of state
benefit payments.

Although important steps have been made in the past to tackle child poverty, the proportion of
the UK population living in poverty has remained high, above the European Union average
and is worse than France, Germany, the Netherlands and the Nordic countries. 11

The Marmot Report also talks about the taxation system in Britain, noting how the benefits of
lower direct tax rates for those on lower incomes are cancelled out by the effects of indirect
taxation. As a result, overall tax, as a proportion of disposable income, was found to be
highest in the bottom quintile. It went on to argue that the tax and benefit system needed to be
overhauled to strengthen incentives to work for people on low incomes and to increase
simplicity and certainty for families. In addition, more needed to be done to redistribute
income without harming the economy by delivering a net tax cut to people who currently face
weak incentives to enter work or to increase their low levels of pay.

11
Lundberg O, Åberg Yngwe M, Kölegard Stjärne M, Björk L, & Fritzell J (2008) The Nordic experience: welfare states and
public health. Stockholm: Centre for Health Equity Studies.

34
Since the Report was published, a financial crisis which resulted in a massive public bailout
of the banking and credit regime has come and gone, leaving the country with a large public
budget deficit. Although the government has highlighted fairness in their policy
announcements, unfortunately changes to the tax and benefits appear to run in the opposite
direction to what was recommended by the Marmot team. According to the Institute of Fiscal
Studies, the overall effect is regressive and the government’s budget cuts will hit the poorest
hardest. 12 Marmot himself raised concerns in his acceptance speech as BMA president in June
2010. He made an impassioned plea to the medical profession to be more involved in tackling
health inequalities and social injustice. 13 A short excerpt from his speech follows:

Both in research and policy I have emphasised the circumstances in which people are
born, grow, live, work, and age. These all loom larger as causes of health inequalities
than defects in our healthcare system. Heart disease is not caused by statin deficiency;
stroke is not caused by deficiency of hypotensive agents. I have emphasised not just
the causes of health inequalities - behaviours, biological risk factors - but the causes
of the causes. The causes of the causes reside in the social and economic
arrangements of society: the social determinants of health.

Commonly, when we think about action to reduce health inequalities, we debate

whether we should focus on smoking, or obesity, or immunisation. Let us remember
Halfdan Mahler, the legendary director-general of WHO. In a speech to the World
Health Assembly in the mid-1980s Mahler said: “Imagine you are up to your neck in a
swamp, fighting alligators; just remember we came to drain the swamp in the first
instance.”

Colleagues, if we really want to fight the alligators of health inequalities, we have to

drain the swamp. We have to deal with the consequences of an unfair set of economic
and social arrangements, and with the causes and the causes of the causes of health
inequalities.

12
Browne J and Levell P, 2010. The distributional effect of tax and benefit reforms to be introduced between June 2010 and
April 2014: a revised assessment. http://www.ifs.org.uk/publications/5246
13
Michael Marmot Speech. Available at http://www.bmj.com/content/341/bmj.c3617.extract

35
Many of the effects of national policies that impact on the living and working conditions of
people are seen in emergency departments and hospitals, or hidden out of sight in squalid
homes, betting shops, sweat shops, or in prison. The NHS and many of the frontline services
provided by local government are fighting the ‘alligators’, and mostly doing a good job. But
Marmot’s call is for the health profession to work on draining the swamp as well.

There is perhaps relatively little that can be done at the local level to “drain the swamp”. But,
if the changes recommended by the Marmot Report are to be made, there needs to be a
paradigm shift in the way we structure and organise our society, and the development of a
broad-based social movement around health and well being. This is something that fits with
the broad democratic mandate of local government, as well as the government’s ideas around
a Big Society. This public health report, we hope, will act as a small contribution to the
emergence of a more informed local discussion.

E. Create and develop healthy and sustainable places and communities

The fifth policy area of the Marmot Report concerns the physical and social characteristics of
communities. The report, for example, highlights the concept of ‘social capital’, which
describes the links that bind and connect people within and between communities. Such links
provide a source of resilience against illness through social support and networks. In the
words of the report, “the extent of people’s participation in their communities and the added
control over their lives that this brings has the potential to contribute to their psychosocial
well-being and, as a result, to other health outcomes”.

Building healthier and more sustainable communities also requires a healthy and sustainable
environment. At the current point in time, there may be nothing more important than
addressing the frightening prospect of climate collapse. It is remarkable how little climate
change features as a priority within the NHS. Given the failure of multilateral negotiation at
the Copenhagen Summit, as well as the limited progress at the recent Cancun Summit in
Mexico, many people are making the case that efforts to reduce carbon emissions require a
more bottom-up approach in which local governments can play a vanguard role.

36
Among the recommendations of the Marmot Report are improving active travel; improving
the availability of good quality open and green spaces; improving the food environment in
local areas; and improving energy efficiency of housing - all in a way that works across the
social gradient. The report challenges local governments, and other actors, to better integrate
local planning, transport, housing, environmental and health systems, and to support locally
developed and evidence-based community regeneration programmes that remove barriers to
community participation and action, and social isolation. Key to this policy area is the local
development framework (the local spatial planning strategy).

Although few of these recommendations are concerned with ‘core’ NHS budgets and
services, the Primary Care Trust has been able to initiate some projects and interventions
related to this policy area of the Marmot Report. For example, the Bike It Project was aimed
at promoting active travel by working with schools to develop a pro-cycling culture: In
schools participating in ‘Bike It’, the number of pupils cycling regularly increased from 17%
prior to the start of the project to 34.6% at the end of the first year. The project has also led to
an increase in the numbers of children who own or have access to a bike.

Such efforts by the PCT may become even more significant in light of the announcement that
funding for the School Sports Partnership will be cut. This may create a big dent in efforts
within London to support pupils to develop an active interest in sport. There is a need to
conduct a local health impact assessment of such possible cuts and to examine the full
potential of local actors to mitigate any detrimental effects.

When it comes to housing, the PCT has been working with the local authority and third sector
partners to produce a specific joint strategic needs assessment on housing and health. Limited
progress has been made thus far, and will need re-energised attention, particularly in light of
the pending cuts in housing benefit. A recent report by the Department of Work and Pensions
estimates that more than 930,000 households across the country will be hit, of which 450,000
will be families with children. The report also goes on to express concern about the potential
negative impact on child health as a result of disruption to schooling, homelessness and
overcrowding. It is unclear what the effects will be in H&F, but again, there is a need for a
health impact assessment to be conducted.

37
The local ‘food environment’ is also important. As will be discussed in the next chapter, the
epidemic of obesity in this country is partly the result of an ‘obesogenic environment’ which
includes of a number of conditions that result in unhealthy diets. One of these environmental
conditions is the prevalence of cheap, fast-food outlets. Currently, the local public health team
is trying to engage with local fast food outlets. It has carried out a series of structured
interviews with the owners of fast food outlets; and together with the environmental health
department in the council, has started testing some popular foods to measure their sugar and
fat content. Among the findings is a lack of knowledge and understanding amongst managers
and owners about healthy food standards, but a desire to learn more. But support from local
politicians, business leaders and community leaders may be needed to generate a genuine
commitment to work on a shared agenda of improved health.

F. Strengthen the role and impact of ill-health prevention

The final policy area highlighted by the Marmot Report mainly concerns traditional ill-health
prevention programmes such as immunisations, cancer screening, health visiting and school
health services. However, the report bemoans the lack of spending by the NHS on ill-health
prevention: “only 4 per cent of NHS funding is spent on prevention”.

It goes on to recommend greater investment in ill-health prevention; improving the scale and
quality of medical treatment programmes; paying greater attention to public health
programmes to reduce smoking and alcohol consumption; and addressing the causes of
obesity across the social gradient.

Here in H&F, we have an effective stop smoking service; a number of services to address the
high rate of admissions and hospital attendances caused by alcohol-related harm; and
strategies and plans to improve the uptake of screening programmes and immunisation
coverage. For some years, H&F has fallen well below the national targets set for
immunisation coverage. Recently however, through improvements in the information system
and targeted approaches, we have begun to hit some of the national immunisation coverage
targets.

The government’s public health white paper ‘Healthy Lives, Healthy People’ has since been

38
published and places a strong emphasis on all actors to improve public health performance -
not just dedicated public health teams and specialists. Of particular importance is the role of
primary care and GP Practices in the delivery of immunisations, screening programmes and
brief interventions around healthy behaviour. Their role in the promotion of health in
Hammersmith and Fulham is discussed in more detail in chapter five, but the next chapter
first discusses the problem of child obesity.

39
Chapter 4: Obesity - more than an issue of fatness

This chapter discusses the major public health challenge of rising levels of obesity,
particularly in children; and is also used to illustrate the need to swim upstream. There are
other health issues that also deserve attention and illustrate the need to ‘swim upstream’ (for
example, mental health) but some features associated with child obesity are unique and
deserve special mention.

Overweight and obesity prevalence

The rise in levels of overweight and obesity 14 is described as an ‘epidemic’ for good reason
(see maps below). The World Health Organisation (WHO) estimates that in 2005, more than 1
billion people worldwide were overweight and more than 300 million were obese. Two thirds
of the world’s population now live in a country where overweight and obesity kills more
people than underweight.

The rising prevalence of obesity in boys worldwide, 1990-2006

(Source: International Obesity Taskforce)

Overweight and obesity is now one of the five leading global risks for mortality worldwide,

14
Overweight and obesity is assessed using the Body Mass Index (BMI) defined as the weight in kilograms divided by the
square of the height in metres (kg/m2 ). A BMI in adults over 25kg/m2 is defined as overweight, and a BMI of over 30 kg/m2
as obese. Measuring obesity in children is modified due to the different rates of change in their height and weight change.
Age and sex-specific UK National BMI centiles classification charts are used to assess the weight of children. Thresholds for
defining overweight and obesity in children are as follows:

• Overweight is defined as a BMI greater than or equal to the 85th centile but less than the 95th centile (i.e.
overweight but not obese);
• Obese is defined as a BMI greater than or equal to the 95th centile.

40
being responsible for 5% of deaths globally. In addition, 19% of all global deaths are caused
by five diet-related risks combined with low levels of physical activity.

Within the WHO European Region, the number of obese people has tripled in the last two
decades resulting in about 130 million obese and 400 million overweight persons today. Over
50% of the adult population in the EU is now overweight or obese, and the same for about
20% of children.

Obesity is a risk factor for many conditions including cardiovascular disease, cancer and
mental illness. The impact on children is especially worrying. There is a growing incidence of
type-2 diabetes in children which was previously rare, and there are concerns about the
psychological impact of obesity particularly with regard to stigma, bullying and low self-
esteem.

Childhood obesity is also a risk factor for future adult disease. Interventions to prevent
childhood overweight and obesity should therefore also be encouraged as a means of
preventing a large proportion of our current children from experiencing a future life of
chronic ill health.

There are also economic impacts associated with obesity and overweight, which are estimated
to have cost the NHS £55.4 million in 2010 for the management and treatment of diseases
related to obesity 15. These figures are for NHS expenditure only and exclude the wider
societal costs of lower productivity, lost output, increased level of morbidity and increased
social care needs associated with overweight and obesity.

The Causes of Obesity

Understanding the causes of obesity are critical because the ‘treatment’ of obesity is at best
difficult. Obesity needs to be prevented.

15
The costs have been estimated using the national estimates calculated by Foresight. A microsimulation model was used
to forecast costs to the NHS of the consequences of overweight and obesity. No inflation costs, either of prices generally or
healthcare costs in particular, were incorporated within the costs, so this allows for direct comparison to current prices.

41
At the simplest level, obesity results from a positive energy imbalance: more energy goes into
the body than is burnt off. Energy intake is determined by eating-related behaviours which are
in turn determined by social, cultural and environmental factors. Similarly, environmental
factors influence the extent to which individuals are able to burn off the energy they consume.

The importance of social factors is highlighted by the consistent social gradient in the
prevalence of obesity. It has been estimated that 20-25% of the obesity found in men, and 40-
50% of the obesity found in women in Western Europe can be attributed to differences in
socio-economic status.

Not infrequently, obesity has been labelled a disease of affluence. In reality, within high-
income countries, obesity and overweight is concentrated amongst the poor. Several studies
have found that the food eaten by economically poorer individuals is higher in energy, lower
in micronutrients and contain less fruit and vegetables. Children from poorer families tend to
drink more soft drinks; and physical activity levels among adults and children in lower socio-
economic groups is lower as well. But even in poor countries where under nutrition and
hunger is prevalent, obesity is becoming a problem, causing such countries to suffer from a
‘double-epidemic’.

Obesity is also commonly referred to as a ‘lifestyle disease’ but explanations focused on

individual lifestyle choices around diet and exercise are inadequate. It is necessary to
understand obesity as a social and collective problem, rather than just an individual problem.

The diagram below provides a useful representation of how child obesity is the outcome of a
set of complex biological and social factors that operate at multiple levels - from the level of
the human cell, to the individual and his / her family, through to the level of society more
generally. Fatness is about far more than just eating and exercise.

42
 Systems Map of Obesity (Source: Foresight Systems Map)

There is still much that we remain unsure of regarding the pattern of the obesity epidemic. For
example, why are fat mothers associated with fat daughters, but not fat sons? And why are fat
fathers more closely associated with fat sons rather than fat daughters?

We know that genes play a role by causing some individuals to have a greater propensity to
becoming overweight or obese. There isn’t anything like a ‘fat gene’ that makes obesity
inevitable; but some role is played by our genetic inheritance. As a species, our genetic
predisposition to obesity has been shaped over millions of years and cannot explain the
sudden explosion of fatness in society. Environmental factors play a big role. This includes
the immediate biological environment of genes, especially in utero and in early childhood.
Epigenetic factors are things that interact with genes and which can cause them to be switched
‘on’ or ‘off’. A foetus with a genetic propensity for adult disease will have a higher risk of
actually becoming diseased if exposed to stress or maternal diabetes during pregnancy. The
same principle applies to the genetic propensity for becoming fat.

When it comes to growth patterns in childhood, there is also some evidence that the trajectory
is largely determined by the time children reach the age of 5 years. The implication of this is
that preventative strategies are best aimed at pre-school children and their families. This also
implies that in order to prevent child obesity, adults need to be targeted.

Linked to the importance of early childhood is the role of breast-feeding in protecting against
obesity in adulthood. One study found a 4% risk reduction of being overweight in adult life

43
for each additional month of any breast-feeding in infancy. Breast-feeding is therefore good
for both child and adult health; exclusive breast-feeding in the first months of life is much
better than partial breast-feeding. However, the prevalence of exclusive breast-feeding until 4
months is low in the UK, especially when compared with other European countries. In
Hammersmith and Fulham, the exclusive breast-feeding rate at six weeks is 45-55%.
However, nearly a quarter of six week old babies are not breast-fed at all in the borough.

Low levels of physical activity and sedentary behaviour have also been implicated. Physical
activity helps to burn calories, which in turn can help prevent weight gain. However, once
children have become fat or obese, increasing physical activity is not always an effective
means of losing weight. Children who are obese find it difficult to sustain physical activity
due to factors at the cellular and biochemical level; rarely are children fat and inactive
because they are lazy. The implication, once again, is that we need to prevent obesity; not
treat it; with a strong emphasis needing to be placed on energy intake in early childhood.

The limited impact of physical activity on reducing weight does not mean that physical
activity is an unimportant element of child health. Healthy levels of physical activity
contribute to improved physical and emotional health in many other ways.

The genes we have inherited from our ancestors were shaped over hundreds of generations in
an environment that is completely different from the one we have now. Of importance, is the
widespread availability and consumption of high-calorie foods and drinks with high sugar;
products that are well marketed, cheap, ubiquitous and addictive. It is therefore important to
avoid trivialising obesity as an outcome of personal choice.

We also know that psychological processes are at play. For example, recent research suggests
that many individuals develop behaviours that are learnt or mimicked from those around
them. We eat the way other people eat, and this may help explain some of the social
clustering of obesity. For young children, this mimicking effect may mean that healthy eating
patterns can often only be properly established through interventions targeted at families; and
for older children, the over-consumption of sugar, salt and fat may need to be tackled through
interventions aimed at entire peer groups and not individuals.

44
Child obesity in H&F

In Hammersmith and Fulham, about one in eight children in state school reception year and
about one in four in state school year 6 are obese. These rates are similar to national and
London-wide averages. However, they only apply to children in state schools. About 30% of
pupils in Hammersmith and Fulham go to private schools for which we have no data;
however, it is likely that the prevalence of obesity in these children is lower than those in state
schools.

Boys tend to be more overweight and obese compared to girls; and rates of overweight and
obesity are higher in the Caribbean and Black African ethnic group compared to the White
ethnic group 16 17
. There is also an association between deprivation and obesity, especially
amongst children in reception year.

Prevalence of obesity in reception aged pupils (Source: NHS Information Centre, 2008/09)

16
Sproston K, Mindell J. Health Survey for England 2004. Volume 1: The health of minority ethnic groups.London: The
Information Centre for Health and Social Care; 2006.
17
The Information Centre, 2009, National Child Measurement Programme: England, 2008- 09 school year NCMP report
2008-9

45
 Prevalence of obesity in year 6 aged pupils (Source: NHS Information Centre, 2008/09)

The high prevalence of obesity is corroborated by other data such as the poor state of oral
health amongst children which is caused in some part by poor diet, especially the
consumption of sugary drinks.

Preventing Childhood Obesity

It is hard to treat childhood obesity. And it is hard to reverse the long-term negative effects of
poor nutrition in childhood. Furthermore, the ill-effects of over-consumption of sugar and fats
impact on children before they become obese. This points to the need for a more effective and
better resourced prevention agenda.

This in turn points to the need for a societal approach aimed at changing the obesity-
generating environment. Most important are efforts to improve food and eating patterns – less
sugar and fewer unhealthy fats, especially in the early years; and more exclusive breast-
feeding in the first six months of life.

46
While there is a need to promote healthy eating choices; more effort also needs to be aimed at
discouraging the production and availability of unhealthy foods, and doing the opposite with
healthy foods.

On the whole, people are generally informed of the danger of being overweight. There is a
good level of awareness about healthy and unhealthy diets. Most people are aware of the
recommended five fruits and vegetables a day. What is more difficult to change are habits and
behaviours, as well as the social, cultural and environmental barriers to the adoption of
healthy shopping, cooking and eating. For large sections of the population, life is high-
pressured, fast-paced, stressful and insecure; and unhealthy eating is part of the coping
mechanisms of many people. Food with lots of sugar provide comfort; greasy fast foods
provide convenience and affordability; and trans fats help provide longer shelf and fridge
lives for food.

Much needs to be done with families and communities through nurseries, children’s centres,
schools and other locations; but there is also much to be done with upstream interventions
aimed at the food industry as well as through urban planning. The Foresight report from 2009,
commissioned by the government to produce a long-term vision of how to tackle obesity,
emphasised that efforts should not be over-reliant on individual responsibility or fragmented
short term initiatives, but that a shift in society and the environment as a whole was required.
Similarly, the BMA has noted that “in order to halt the obesity epidemic, interventions at the
family or school level will need to be matched by changes in the social and cultural context so
that the benefits can be sustained and enhanced” 18.

One public health nutritionist made the point more strongly by saying that we should not kid
ourselves into thinking that the obesity problem will be resolved without fundamental change:
“ ….an earthly cynic, might suggest that obesity actually contributes positively to the global
economy (greater food consumption, bigger clothes, labour-saving devices, motorized
transport, even incomes generated by variably effective treatments and token gym
memberships). All of these create ‘wealth’. Therefore, it is not surprising that prevention
budgets are orders of magnitude less than the marketing of budgets for individual carbonated

18
BMA, Preventing Childhood Obesity, 2005; www.bma.org.uk

47
drinks or chocolate bars, or that sports fields are sold for building, roads are widened
without cycle or pedestrian tracks and that portion sizes increase. Are current efforts at
obesity management and prevention expressions of cynical tokenism?” 19

So what can and should be done? There are no magic bullets to address this problem. As
described earlier, the causes are multi-factorial and the solutions involve a mix of
interventions and policies, and a wide range of actors. If we treat child obesity not just as a
health problem in its own right, but also as a marker of other health needs (e.g. poor oral
health, poor child care and psychological / emotional ill health), there are grounds to identify
child obesity as a social and public health priority which needs to be tackled.

In light of this, we propose that the local NHS and council in H&F organise a ‘health summit’
in 2011 to discuss, debate and develop an agenda for tackling childhood obesity. This should
involve experts in the field; practitioners, councillors; and members of the public. Such a
summit should not just be a high profile talkshop; but rather a moment during which
commitment to bold action is galvanised. It should therefore be preceded by several months
of preparatory work.

19
M E J Lean, Childhood obesity: time to shrink a parent (Editorial) International Journal of Obesity 34, 1-3 (January 2010)

48
Chapter 5: General Practice - a platform for more

Introduction

Approximately £355 million of NHS money is spent on Hammersmith and Fulham residents.
A large proportion of this funding is spent on hospital services (see below).

Budget allocations across service sectors in Hammersmith and Fulham

Financial Year 2010/11

Some of the spend in hospitals is for the treatment of conditions that could either be prevented
or managed more cost-effectively in the primary care setting. There is also an amount of high-
cost expenditure on patients during the terminal stages of their lives, some of which may be
inappropriate or unwarranted; and on certain high cost drugs of questionable value.

49
Money spent in one part of the NHS means less money available elsewhere and there is an
argument that the NHS budget could be better used if more of it were directed at more cost-
effective primary and preventative health care.

But this is easier said than done. Hospitals have a remarkable ability to generate activity and
expenditure. Efforts to reduce avoidable and expensive hospital expenditure have proven
difficult. Reducing or rationing access to high-cost, limited-value cancer drugs is
controversial and hindered by well-funded treatment lobby groups, and there is a tendency
within the NHS to privilege hospitals and clinical treatment over primary and community care
and over preventive and public health programmes.

According to the Public Health White Paper, “Public health budgets have been squeezed.
Prevention has not enjoyed parity with NHS treatment, despite repeated attempts by
government to prioritise it. Public health funds have too often been raided at times of
pressure in acute NHS services and short-term crises”.

Various plans and strategies exist in Hammersmith and Fulham to reduce the level of low
value and avoidable activity in hospitals. These include plans for an integrated care initiative
to improve the management of diabetes and elderly patients; reducing hospital activity on
procedures of low cost-effectiveness; and helping people stay healthy.

One of the key planks for delivering these plans and strategies is the primary care network of
GP practices and community-based health services (mainly provided by CLCH). This
network should be the bedrock of any health system. By being close to communities and
patients, and by straddling the treatment-prevention divide, primary care providers are also
well placed to advocate on behalf of communities and patients, and project a holistic and
comprehensive overview of health care provision. Across the NHS as a whole, an estimated
90% of all contacts take place in general practice (amounting to about 300 million
consultations a year across England). Of these contacts, 90% involve diagnosis and treatment
without referral to hospitals 20.

20
King’s Fund Briefing - General Practice in England - an Overview, September 2009

50
Many health systems experts also see primary care as a platform for the provision of non-
medical care and services, including social care, patient empowerment programmes, stop
smoking services, nutrition support and even housing and benefits advice. In this way,
primary care is a platform for both clinical and public health delivery.

The NHS White Paper recognises the importance of primary care by shifting greater influence
and responsibility to GPs and forcing GPs to adopt a more population-based approach to
health improvement. It is therefore timely to describe and discuss the existing GP landscape
in the borough. Ideally, we would accompany this with a review and analysis of CLCH’s
services as well; and this is something we hope to do in the future.

GP Practices in Hammersmith and Fulham

Hammersmith and Fulham has 31 GP practices in total. These range from single-handed
practices with over 2,000 patients, to large multi-partner practices with 15,000 patients.

The staffing patterns of GP practices vary considerably. Some are small and consist of only a
doctor, health care assistant and receptionist. Others have multi-disciplinary teams consisting
of doctors, nurses, health care assistants and a practice manager. In addition, some GP
practices have district nurses and other types of clinical staff who belong to other health care
organisations but who are co-located on the same premises.

As far as doctors are concerned, there are an estimated 94 whole time equivalent (wte) GPs
working in Hammersmith and Fulham. Six practices employ a single GP; at the other extreme
is a practice that employs 9 GPs.

The average number of patients per wte GP in H&F is 2,339, which is higher than the London
average of 1611 (see table below). Thirteen practices exceed the Hammersmith and Fulham
average, with a wide range from 875 to 3622 patients per wte GP.

51
Variation in average no. of patients per GP, Practice Nurse and Direct Patient Care wte
across Hammersmith & Fulham (Source: GP Balanced Scorecard, March 2010)

and practice nurses)

patients per GP wte
Average number of

Average number of

(excluding doctors
patients per direct
Average no. of pts
per practice nurse

patient care wte

Area in H&F

wte
North 2,579 5,538 51,860
North Central 1,971 6,119 133,311
South Central 2,120 5,026 64,654
South 2,685 6,487 155,229
H&F 2,339 5,793 101,264
London 1,611 - -

The PCT recently surveyed general practices in H&F to establish baseline data on the grades,
responsibilities and training needs of practice nurses. Only 25 practices responded of which
24 employ 32 nurses as part of the primary health care team. 17 practices employ one nurse; 6
practices employ two nurses; and 1 practice employs three nurses. One practice had no nurse
due to being on maternity leave. The number of contracted practice nurse hours per week also
varies, ranging from 0 hours a week to 99 hours per week.

These variations in the staffing of GP practices will result in different patient experiences
from one practice to another as well as differences in the quality of health care provided.

Varying patient populations

GP practices also vary in terms of the age, socio-economic and ethnic mix of their registered
populations. One commonly used proxy indicator of health need is the Index of Multiple
Deprivation (IMD) which combines a number of measures of deprivation into a single score
for an area. The table below describes the patient population of 28 local GP practices
according to the IMD score of each patient’s home address. It shows that GP within H&F

52
practices serve quite different populations: the median IMD score of practice patient
populations ranges from 16 (least deprived) to 44 (most deprived).

Distribution of IMD Score by Hammersmith & Fulham Practice

(Source: Index of Multiple Deprivation 2007)

When we plot the IMD scores of patient populations by GP practice onto a map, the north-
south geographic divide in Hammersmith and Fulham becomes apparent. Practices with more
deprived patients tend to be both smaller in size and clustered in the North (the different
patient population size of different GP practices are represented below by the different sizes
of the coloured circles).

53
 Map to show average IMD Score and practice list size by location of Hammersmith &
Fulham Practice (Source: Index of Multiple Deprivation 2007; Ordnance Survey)

Quality of Care

Measuring the quality of care amongst GP practices is important if standards of performance

are to improve and be equalised across the borough. One dimension of quality is ‘access’.

Weekly clinical hours per 1,000 patients describes the total number of hours that a clinic is
open for patients to attend in a week, taking into account the size of their patient list. This
indicator of access varies four-fold from 3.72 per 1,000 to 16 per 1,000 patients, with
practices in the North Central area having the lowest number of clinical hours offered to
patients.

Some measures of access are derived from the GP patient survey conducted by Ipsos Mori.
There are many limitations to this survey in terms of validity, recall bias and response rate.

54
Nonetheless, the survey points again to considerable variation in the quality of care. For
example, patient satisfaction with 48 hour access varies from 51% to 98% with an average of
74% (December 2009); while patient satisfaction with phone access in the same period varied
from 45% to 85% (with an average of 65%).

The national GP patient survey also contains questions on satisfaction with nursing provision.
The chart below shows the scores for satisfaction with access to nursing services in all H&F
practices for Q3 of 2009/10. Again, we see data suggestive of undesirable variations in patient
experience.

% of patients who found it easy to get an appointment with a Practice Nurse and % who
rated the amount of time seen by the Practice Nurse as good in Hammersmith &
Fulham practices (Source: GP Patient Survey)

As far as overall patient satisfaction is concerned, in December 2009 the average rate was
85% which compares well with a London average of 86% and a national average of 90%.
However, the variation across individual practices ranged from 92% to 72%.

There appears to be a fairly strong correlation between levels of patient satisfaction and
deprivation. Practices serving a higher proportion of patients living in areas with high

55
deprivation tend to have lower levels of patient satisfaction. The reason(s) for this are not
entirely clear.

Overall patient satisfaction by IMD Score for Hammersmith & Fulham practices
(Source: GP Patient Survey; Index of Multiple Deprivation 2007)

Another proxy indicator of quality is the percentage of patients on a GP list who have not
been seen in the last 3 years. The assumption is that a high proportion of patients not seen in
the last 3 years indicates a lack of engagement with patients (although there are other possible
explanations such as having a healthier list of patients with less need to visit the GP). In
March 2010, the average number of patients not seen in the last 3 years in H&F was only
4.5%, but with a range from 0% to 25%.

It should be noted, however, that many of these measurements depend on GP practices having
accurate patient registers. However, we know that due to the high population turnover and in
some cases, inadequate regular ‘cleansing’ of GP patient lists, population-based indicators
relating to GP practices are subject to a degree of error.

Patient attendance at urgent care centres

The high rate of patient attendance at urgent care centres could be a result of dissatisfaction
with the practice or an indication of high patient need. The two graphs below display first, the
correlation between attendance at urgent care centres and deprivation, and second

56
between attendance at urgent care centres and patient satisfaction with practice (from the GP
survey). The first graph shows that the rate of patient attendance at urgent care centres ranges
from 1.3 per 100 patients to 12.4 per 100 patients, with an average of 5.0 per 100 patients.
Furthermore, patients from practices with a high deprivation score appear more likely to use
the urgent care centres. It is interesting to note that the second graph shows little correlation
between the use of urgent care centres and the recorded level of patient satisfaction with the
practice; even though one might expect low levels in patient satisfaction to result in a higher
usage of urgent care centres.

Rate of attendance at Unscheduled Care Centres per 100 patients by IMD Score for
H&F practices (Source: GP Balanced Scorecard; Index of Multiple Deprivation 2007)

Rate of attendance at Unscheduled Care Centres per 100 patients by Overall patient
Satisfaction for H&F practices (Source: GP Balanced Scorecard; GP Patient Survey)

57
Long term conditions management

The management of long term conditions in primary care also shows variation. The first step
in effective long term conditions management is to identify individuals with long term
conditions so that they can be placed on a register and be subject to pro-active clinical
management and monitoring. When one compares the number of individuals who are listed
on disease registers with the number of individuals that one would ‘expect’ to see, it becomes
apparent that a significant proportion of individuals with chronic diseases either remain
undiagnosed or unrecorded.

The chart below shows the discrepancy between estimated prevalence of diabetes and actual
recorded prevalence of diabetes, by GP practice and practice IMD score. The chart shows
significant variation between practices, with a number of practices having a 1 to 2% gap
between estimated and recorded prevalence, whilst other practices have no or hardly any gap.
The chart also shows an inverse relationship between the extent of the gap and the practice
IMD score: the higher the practice IMD score (i.e. the more deprived the practice population)
the smaller the gap between expected and recorded prevalence. The probable reason is that
practices with lower IMD scores in H&F are often practices that also have higher proportions
of older people, and we know that diabetes is common amongst older people. We will further
investigate and report back on this in next year’s annual public health report.

Median IMD by the difference between estimated & recorded diabetes prevalence for
H&F practices (Source: NWPHO; Index of Multiple Deprivation 2007)

58
Another example is the under-recording of children with asthma. The true prevalence of
asthma in children (as measured through surveys) is around 10-15% among the 2 - 4 year
olds, gradually increasing to 25% among the older teenagers. However, according to GP
practice records, only 6.8% of the overall child population in Hammersmith and Fulham has
been diagnosed with asthma. The chart below shows that less than 1% of children between 0
and 4 years of age were diagnosed with asthma, which compares very unfavourably with the
known prevalence of 10 – 15% among 2-4 year olds. We can also see significant variations
between practices in their levels of picking up childhood asthma. A large number of children
with mild asthma are probably being diagnosed incorrectly with conditions such as wheezy
bronchitis or chest infections. We suspect that many of these patients are seen at A&E or
other urgent care centres and being treated with antibiotics when in fact they need to be
treated with asthma medication. Addressing this problem would not only achieve significant
cost savings, but could make a considerable improvement to the health of many children.

Table to show the prevalence of Asthma and hospital admissions for Asthma by GP
practice in Hammersmith & Fulham
(Source: GP Patient Records; SUS)

Asthm a Register (Jan 2011) Em ergency adm issions via A&E (18 m onths) OP appointm ents (18 m onths)

patients/ patients /
GP Practice Organisation: GP Practice Name asthma register registered pop prevalence patients asthma register IP admissions patients asthma register OP appointments
E85003 North End Road Medical Centre 189 2230 8.5% 6 3.2% 8 16 8.5% 50
E85005 The Surgery, Dr Dasgupta & Partners 35 936 3.7% 5 14.3% 6 7 20.0% 12
E85008 Lillie Road Surgery 120 1455 8.2% 13 10.8% 17 15 12.5% 75
E85016 Richford Gate Medical Practice 169 2201 7.7% 4 2.4% 4 11 6.5% 30
E85020 Brook Green Medical Centre 86 1507 5.7% 3 3.5% 4 6 7.0% 22
E85025 Cassidy Road Medical Centre 52 515 10.1% 3 5.8% 3 2 3.8% 8
E85029 The Medical Centre, Munster Road, Dr Jefferies 324 2268 14.3% 3 0.9% 8 18 5.6% 61
E85032 Ashchurch Surgery 48 1075 4.5% 5 10.4% 8 6 12.5% 25
E85033 Hammersmith Surgery, Dr Fernandes 113 1601 7.1% 5 4.4% 10 6 5.3% 13
E85037 Southall Surgery, Dr Uppal & Partners 54 823 6.6% 3 5.6% 4 1 1.9% 6
E85038 The Surgery, Dr Mangw ana & Partners 13 685 1.9% 0 0.0% 0 3 23.1% 8
E85042 The New Surgery 76 946 8.0% 2 2.6% 2 9 11.8% 22
E85048 White City Health Centre, Dr Dandapat 94 903 10.4% 3 3.2% 4 3 3.2% 3
E85055 The Bush Doctors 142 1721 8.3% 6 4.2% 9 8 5.6% 14
E85074 Brook Green Surgery 62 702 8.8% 3 4.8% 4 1 1.6% 5
E85077 Shepherds Bush Medical Centre 17 516 3.3% 0 0.0% 0 2 11.8% 24
E85110 The Surgery, Dr Das & Partners 42 443 9.5% 4 9.5% 9 2 4.8% 2
E85118 Fulham Medical Centre 63 1462 4.3% 1 1.6% 1 4 6.3% 10
E85124 Lillie Road Health Centre 50 587 8.5% 0 0.0% 0 1 2.0% 3
E85125 Sterndale Surgery 50 1082 4.6% 1 2.0% 3 12 24.0% 39
E85128 Sands End Clinic 76 1522 5.0% 4 5.3% 4 6 7.9% 17
E85624 White City Health Centre, Dr Uppal 26 591 4.4% 4 15.4% 4 19 73.1% 36
E85636 Park Medical Centre 156 2133 7.3% 3 1.9% 4 7 4.5% 15
E85649 Fulham Cross Medical Centre 12 210 5.7% 0 0.0% 0 1 8.3% 1
E85659 White City Health Centre, Dr Mirza 27 490 5.5% 1 3.7% 1 0 0.0% 0
E85672 Salisbury Surgery 21 202 10.4% 2 9.5% 3 3 14.3% 15
E85673 Old Oak Surgery 61 1180 5.2% 0 0.0% 0 4 6.6% 19
E85685 Lillyville Surgery 73 1601 4.6% 2 2.7% 2 23 31.5% 74
E85719 Ashville Surgery 109 2574 4.2% 8 7.3% 12 13 11.9% 29
E85748 The Medical Centre 61 1466 4.2% 2 3.3% 2 1 1.6% 2
Y02589 Hammersmith and Fulham Centres for Health 24 324 7.4% 0 0.0% 0 0 0.0% 0
Y02906 Canberra Centre for Health 18 361 5.0% 0 0.0% 0 0 0.0% 0
Grand Total 2463 36312 6.8% 96 3.9% 136 210 8.5% 640

59
When it comes to the effective clinical management of long term conditions, there are further
variations seen across practices. For instance, in March 2010, the percentage of patients with
diabetes in whom the last measured HBA1c (a measure of the control of blood sugar) was
adequate in the previous 15 months varied from 38 per cent to 83 per cent, with an average of
58 per cent across all practices. Again, practices with higher deprivation scores tend to have
lower percentages of patients with well controlled diabetes.

IMD Score by % with HBA1c 7.5 or less

(Source: QMAS, Index of Multiple Deprivation 2007)

The Quality and Outcomes Framework (QOF) is a voluntary annual incentive programme for
GP surgeries in England. It consists of 4 domains: Clinical; Organisational; Patient
Experience; and Additional Services. Each domain consists of a set of achievement measures,
known as indicators, against which practices score points. As of March 2010, the average
achievement for the clinical domain across Hammersmith and Fulham practices was 91.2%,
but with scores ranging from 53.2% to 99.4%. For the non-clinical domains, the average was
73%, with a range from 29.3% and 80.7%.

60
Prevention services

A number of preventive interventions such as immunisations and cervical screening are

delivered largely through general practices. The chart below shows cervical screening uptake
by practice as at December 2009, showing both the proportion of smears done in the physical
premises of a GP clinic (labelled GMS) as well as the total number which includes smears
performed in other settings such as community family planning services. Again, there is a
large and unacceptable variance in the coverage rates achieved across the patch.

Cervical Screening (%) by GP Practice

(Source: FHS December 2009)

61
There also appears to be some correlation with deprivation, with practices with higher IMD
scores having lower uptake as shown in the chart below.

Cervical Screening (%) by GP Practice by IMD

(Source: FHS December 2009; Index of Multiple Deprivation 2007)

The uptake of the MMR vaccine also shows variation. In 2009/10, it varied from 35 per cent
in the worst performing practice to 100 per cent in the best performing practice. However,
there was a weak association between MMR uptake rates and deprivation scores.

MMR Uptake 2009/10 by IMD

(Source:NCHOD; Index of Multiple Deprivation 2007)

62
The inverse care law

The previous section suggests that performance indicators tend to be worse in those practices
serving more deprived members of the local population. There may be many reasons for this.
For example, such practices may have a higher proportion of ‘hard-to-reach’ patients. Another
reason may be the presence of the ‘inverse care law’. This law states that fewer resources tend
to be available to communities with higher needs (i.e. those living in deprived areas).

To see if the inverse care law operates in H&F for primary care, we need to examine the
availability of resources against a measure of need. Funding for GP practices is complicated.
Public funds flow into GP practices through a number of channels. At least half of practice
income comes from a ‘global sum’ that is based on the number of patients within a practice,
weighted according to their age and gender profile as well as levels of deprivation and ill
health. Adjustments are also made to reflect the costs of recruiting staff in each locality.

A second chunk of funding comes from the national Quality Outcomes Framework (QOF)
which creates financial incentives for practices to achieve certain performance improvements.
Practices receive about £125 per point for an average sized practice and can reach a maximum
of 1000 points. Thirdly, practices can enter into national or local ‘enhanced service
agreements’ which secure payments for meeting specific requirements (e.g. flu immunisations
or targets that have been defined to meet a specific local need). In H&F, there has also been a
‘QOF Plus’ scheme which is an additional incentive scheme linked to set performance targets.
Fourth, additional payments are made to cover the costs of premises, the seniority of GPs
within the practice and IT costs. Finally, for some practices, the dispensing of medicines can
also be a source of significant additional income.

These different forms of funding result in significant variations in the income of GP practices,
and ultimately in the overall per capita spend for GP care.

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 Estimated total payments to H&F practices in 2009/10 (Practice name not disclosed)

In H&F, for the financial year 2009/10, total payments to practices divided by the number of
patients on the practice list varied from £100.86 to £210.18. The graph below suggests that
practices with more deprived patients tend to receive lower payments per capita. This may be
because they are unable to meet some of the incentive-based payments; have lower premises
costs or have fewer senior GPs. But nonetheless, it suggests that the inverse care law exists.

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 Median IMD score by Total per Capita payment per GP Practice
(Source; Index of Multiple Deprivation; QOF)

A more detailed breakdown of the payments to individual GP practices and what they spend
their income on is an important piece of analysis that would enable a deeper understanding of
how primary care services can be developed more equitably, how resources can be used more
effectively, and how individual practices might be changed to develop a more comprehensive
and integrated multi-disciplinary primary care service. As described earlier, it is striking how
GP practices vary in terms of their decision to recruit staff such as practice nurses. By
describing the ‘inputs’ going into a GP practice and then contrasting this against the outputs
and services provided, some estimation of value for money is also made possible.

For example, from some of the data we have, we can analyse how the ‘global sum’ paid to
each practice compares with the number of appointments offered. The chart below compares
this figure against the index of multiple deprivation score for practices and indicates that some
of the practices with the most deprived populations receive lower global sums per patient
appointment than other practices. It is not clear why this is the case because the global sum

65
payments should have taken into account levels of deprivation. Further investigation is
required.

IMD score by global sum’ paid to GP each practice per appointment offered
(Source: Index of Multiple Deprivation 2007; QOF)

Another measure of ‘value for money’ is the percentage of prescriptions issued for generic
drugs. Generic drugs cost less than branded alternatives which are pharmacologically similar.
In December 2009, the average measure for H&F was 82.43 per cent, with a range from 70.86
per cent to 90 per cent.

Conclusion

The White Paper offers a real opportunity to strengthen the primary care foundations of the
NHS, and to ensure effective stewardship over the scarce resources available to meet the
health needs of the local population.

The data presented here highlight three issues. The first is the significant degree of variation
in various aspects of general practice, including in terms of opening hours, staff mix,
availability of doctors and nurses, prescribing practices and quality of care. The second is the

66
fact that practices with higher deprivation scores achieve less favourable results in terms of
access, clinical QOF achievement and uptake of prevention services. The third is that further
analysis is required to understand the way GP income is translated into services, outputs and
outcomes primarily as a means of driving up efficiencies, but also as a means of enabling
cross-practice learning through comparisons and peer review.

This chapter does not describe the way in which GPs work with health visitors, district nurses
and other paramedical staff such as educational psychologists and occupational therapists; but
it’s clear that improvements and efficiencies can be made through better communication and
information sharing; the adoption of shared locality-based strategic priorities and plans; and
the strengthening of inter-disciplinary cooperation, collaboration and mutual respect. In
particular, the management of high-risk individuals with severe, multiple and chronic diseases
will require both multi-disciplinary and multi-organisational teamwork; in which GPs should
help play a critical clinical leadership role.

Similarly, the low immunisation screening coverage rates noted amongst certain GP practice
patient populations may only be adequately improved in some cases if GP practices are able
to work better with community Health Champions, public health workers and third sector
organisations to increase the community’s demand for the uptake of preventative services.

The government’s proposals to hand commissioning responsibility to GP consortia will mean

GPs having to take a more active interest in the total health of the population, as well as the
health of NHS finances. Currently, GPs are contracted and rewarded for delivering mostly a
reactive service. The redesign of the national contract should support a more proactive
approach to planned care and early intervention which in turn should result in significant cost
savings and improved population health.

However, none of the challenges facing the NHS will be met without the involvement of
patients, communities and the public at large. This is a self-evident truth and has also been
made clear in the new government’s policies and proposals for the NHS, as well as in the
Marmot Report. The next chapter discusses the role, value and need to put patients and
communities at the heart of the NHS.

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Chapter 6: Putting the patient and community
centre stage

The Public Health White Paper states that: ‘Individuals should feel that they are in the driving
seat for all aspects of their and their family’s health, well being and care. This applies to
people maintaining their wellbeing and preventing ill health; if they have a long term
condition, keeping as well as possible and managing it to avoid it worsening; and being true
partners in their care so that decisions are shared as far as possible, based on the right
information and genuine dialogue with health professionals’.

For public health as for social care, the vision is services and support delivered in a
partnership between individuals, communities, the voluntary sector, the NHS and local
government.

Similarly, the NHS White Paper is designed to “strengthen the collective voice of patients
and the public” and to inform and empower people with the information they need to make
effective and appropriate choices. The White Paper also notes that public scrutiny is
“essential for ensuring that Government and public services remain effective and
accountable”.

Community empowerment and involvement in health has also been a central pillar of the
World Health Organisation’s vision of ‘Health for All’, and has been shown in numerous
studies to be an important element of ‘good health at low cost’. Too often however, across the
world, patients and communities are treated as passive consumers of medical technologies or
as acquiescent recipients of professional expert opinion.

While much is made of giving power to patients in the form of consumer choice, it is also
well recognised that full and informed choice in health care settings is often unrealistic given
the complexity of medicine, the limitations in readily available information, and the
vulnerable condition of many patients. For this reason, health systems are strongly dependent
on a culture of ethics and professionalism if patients and communities are not be short-

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changed with poor or inappropriate care. Nonetheless, the emphasis on citizen engagement
and community involvement proposed by the current government is to be welcomed.

The importance of patient and community engagement has been recognised within the PCT
through a ‘community engagement team’ working closely to support patient and community
empowerment within the health sector. but as funding cuts begin to bite and as responsibility
for commissioning is shifted over to GP consortia, it will be important to ensure that existing
knowledge, capacities and activities around community engagement are carried forward. This
chapter therefore provides a brief description of the range of community and patient-based
programmes and projects that the PCT has spearheaded over the past few years.

The model and approach

Patient and community engagement in H&F has centred on three priorities: the reduction in
health inequalities; the improvement of self-management of long term conditions; and the
facilitation of individuals and community groups into becoming champions and delivery
agents of both health and health services.

The starting point is an understanding of the needs of local communities. This is done through
an analysis of data; but more importantly, through working with community researchers and
projects to explore what local communities want from their health services and what the best
way to deliver them would be. The approach is based on the principle that PCT staff do not
necessarily have the solutions but can help empower communities and patients to articulate
the problems that currently exist in the system and suggest their own proposals and solutions.

As a result, a key aim has been to build the capacity of the local community and individuals to
analyse existing services; design and develop new proposals; and develop the confidence and
capability to articulate their views and perspectives. The method supports individuals and
communities along a path which moves from ‘being informed’ to ‘giving feedback’ to
‘influencing the design and delivery of services’ to ‘deciding what services should be
delivered and how they should be delivered’.

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What follows are some examples of patient and community engagement that have been
conducted in the borough.

Example 1: Engagement of local communities: White City Health Champions

In White City, an area of social deprivation and poor health outcomes, the PCT has been
working with the Well London Project to set up a team of local Health Champions. Health
Champions are local residents who volunteer to be trained to deliver signposting and
information to other residents about services, campaigns and projects. They also run their own
projects such as exercise groups for women; football tournaments for children; cooking
projects; walking groups; and DIY happiness to promote mental health.

A team of 35 volunteers, including 18 trained Health Champions, have become a live

information and support network for the community, helping to drive forward the redesign of
primary care services centred around the Canberra centre; reaching out to people who do not
typically engage with screening programmes; and undertaking community research to
integrate health, housing and social care services in the neighbourhood.

The data below reflects the numbers engaged in one year by the Health Champions, and also
demonstrate how the role can lead to new career pathways for the volunteers. The real
outcomes are in the longer term public health benefits and in the development of knowledge,
skills and attitudes which lead to better health, especially for marginalised groups. The project
will be extended over the next year to provide information about social care and housing
services as well, and to other deprived neighbourhoods in the borough.

Well London White City - Health Champions:

• Made 800 referrals to local health and social care services

• 4 Health Champions trained and employed as Smoking Cessation Advisors
(180 contacts made on No Smoking Day)
• 3 Health Champions gained employment as Health Trainers; 1 gained
employment at the Canberra Centre for Health; and 3 working as exercise
motivators at the YMCA

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Example 2: Engagement of Individuals in Self Management and Self Care: Expert
Patient Programme

The Expert Patient Programme (EPP) is a structured self-management course which runs over
6 weekly sessions and helps people with long term conditions understand their condition and
improve the way they manage it. It covers pain management, relaxation, diet and exercise,
and finding out more about diseases and how to work better with health care professionals. In
addition it teaches the skill of action planning to address problems that negatively impact on
quality of life. Evaluation of the programme reveals that it improves self-esteem and
competency, and that it reduces the use of health care services dramatically. 21 22
It has been
estimated that each participant can save up to £1800 a year through fewer GP, hospital
outpatient and inpatient visits.

In H&F the EPP has also been delivered with a strong focus on health inequalities and
marginalised groups. Over 700 people have joined courses in the past 5 years with over 50%
from black and minority ethnic groups and people living in social housing. 42% of EPP
participants are either unemployed, unable to work due to illness, or retired. These figures are
far in advance of those from comparable programmes elsewhere in London.

The EPP has also worked closely with existing community organisations such as Nubian Life,
an Afro Caribbean elders group on the White City estate. They have been successful in
training a number of their members as EPP tutors, and in recruiting people who have not been
well to attend courses. One participant came to the graduation and literally threw aside her
walking frame and walked upright without support because of the progress she had made
through the course.

In addition, the EPP has been run in a prison, with the following comment by a participant
illustrating the power of the programme: ‘I had chronic illness prior to being in

21
Kennedy AP et al. Journal of Epidemiology and Community Health. 2007. ‘The effectiveness and cost effectiveness of a
national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled
trial’.
22
Dost A. Internal Monitoring of the Expert Patients Programme. 2005. Department of Health Working Paper

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prison, and being in prison did not make my condition any better. People around me do not
understand why my physical and emotional problems are affecting my decisions, and even I
cannot understand myself at times. But when I take part in this course, I can understand many
in my life now better than before and about most of my decisions taken, and also understand
how other people around me feel about some things I do’

The EPP has trained 28 volunteer tutors who can now deliver courses in Polish, Somali and
English. It has been delivered in community settings and in care homes and day centres, and
with the support and engagement of community groups.

A comment from a participant in the Polish EPP at the Polish Centre said the following: ‘For
the last ten years I am trying to lose weight because I am eight stones overweight. This affects
my blood pressure and my back problems. I tried different diet. I always started them on
Monday and finished just two or three days later. On the course I have learned how to do my
action plan and how to solve the problem. Today I am two stones lighter. Thank you!”

The database of past participants of the EPP acts as a resource in the community. People who
have attended EPP courses are now active as community researchers; as participants in
service redesign; as fieldworkers undertaking mystery shopping to improve services; as local
‘cancer ambassadors’ and ‘diabetes champions’; and as informants in formal consultations
around specific service areas. They engage both as individuals and as members of their
community, driving improvements in their own health as well as the capacity of their
community.

However, despite the evidence that participation in the Expert Patient Programme is effective
in improving patient’s self management, the overall uptake of the programme is very low
compared to the number of people who are known with a long term condition. As shown
below only 1.5% of people with one or more long term conditions have participated in an EPP
course. The low uptake of the Expert Patient Programme among people with a long term
condition is not specific to Hammersmith and Fulham. Having said that, there is much scope
for increasing uptake locally. Key to this will be engaging GPs and other clinicians

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 Low uptake of the Expert Patient Programme among people with long term conditions
in Hammersmith and Fulham (Source: GP Practice Data; EPP Participant Database).

Uptake in %:
Number of adults Number of people proportion of people
with long term who participated who participated in an
conditions in H&F in an EPP course EPP / number of people
(December 2010) during 2005-2010 with a long term
condition
One or more long
48,621 750 1.5%
term conditions
Coronary Heart
3,133 22 0.7%
Disease

Diabetes 5,920 100 1.7%

COPD 1,850 13 0.7%

Asthma 12,404 45 0.4%

Example 3: Engagement of patients in service redesign

Given the challenges facing the NHS in terms of growing demand and limited resources,
service redesign has been a critical part of the work of the community engagement team. One
of the challenges has been to understand why the services which already exist do not work in
the way they were intended, and how they could work more efficiently and effectively.

The PCT has been undertaking a number of service redesign projects, looking at critical areas
such as diabetes services, respiratory services and out-of-hospital care. An example is the
involvement of the Diabetes Service Users’ Group.

Twenty three service users with diabetes were recruited to join a service user group to work
alongside the diabetes service redesign group. Members of the group were selected according
to their willingness to influence services and the demographic make-up of the population with
diabetes. Of the group, 40% were from black and minority ethnic communities; 23% had

73
type-1 diabetes; one had serious mental health problems; one was homeless in hostel
accommodation.

The group met monthly and discussed areas of concern to them about existing diabetes
services, and what could be done to improve them. In particular, they focused on ways to
improve and standardise minimum levels of care in primary care; improve access to
information; and improve patient education and self management.

Four representatives from the group became formal members of the service redesign group
and the diabetes clinical network, and participated in making decisions about a new model of
care. In addition the service user group developed a patient diabetes care charter, which lists
on one sheet of paper everything a person with diabetes can expect from their healthcare
professional, and everything they can do for themselves to improve their health and ability to
manage their condition.

Example 4: Reaching into the community with prevention: Community Health Checks
& Health Trainers

NHS Health Checks is a national programme aimed at preventing cardiovascular disease.

Everyone between the ages of 40 and 74 who have not already been diagnosed with a
cardiovascular condition is to be invited once every five years to assess their risk of disease
and be given support and advice to help them to reduce their risk.

GPs have been offering NHS Health Checks since 2009; but it is well recognised that a large
number of individuals do not take up the offer of a health check in their GP practice. In order
to cover this group of individuals, a more pro-active outreach programme is required. If this is
not done, there is a possibility that the Health Checks programme could worsen health
inequalities by failing to reach those high-risk, hard to reach members of the population.

The PCT has therefore developed a plan to carry out 1,800 health checks in six community
pharmacies and in 12 other community settings to supplement those carried out in GP
practices. Critical to this project is the involvement of Health Champions and Health Trainers.

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To date, 348 health checks have been carried out in these settings with more events in
locations such as shopping centres and pubs in the pipeline.

The community health check programme is also linked to the Health Trainer programme
which is delivered through community organisations. Health Trainers are paid and formally
trained individuals who provide signposting and motivational support. They work one-to-one
with members of the community on personal health plans to stop smoking, lose weight, eat
healthily and become active.

The service has employed 17 health trainers so far, of whom six have moved onto other
careers. A total of 655 individual clients have been engaged since 2008; mainly from the most
deprived or deprived wards in the borough. The experience of one individual provides an
illustration of the potential power and value of the Health Trainer programme: ‘I started this
programme after being referred by my GP, and after six months, it has totally transformed my
life. I was coached on healthy eating and exercise. I took it all and did exactly what I was
guided in. I lost five inches in my waist. This transformation has also trickled down to my
family. We now do regular exercises after school and three hours on Saturdays. We have
started to eat more healthily, with more fruits and vegetables as I now understand the
nutritional value more…. Since seeing the health trainer, I feel much more confident. He’s got
me volunteering on the farm and doing much more exercise. I didn’t think I could socialise
and talk to new people but I can and it feels great. The service is very professional and
supportive.’

Conclusion

The various projects described above need to be seen as a set of synergistic activities. It is
through the Expert Patient Programme that the PCT has been able to effectively involve
patients in service redesign work; it is with the Health Champions that we are able to increase
demand for cervical and breast screening; it is with Health Trainers that community
pharmacies are able to refer some people to support behaviour change. The different projects
also provide a vital bridge between the PCT as a commissioning organisation with the general
public; and help to provide some of the ‘glue’ that is needed to build up healthy levels of
social capital.

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There is, however, a danger that in these financially challenging times, these services are still
viewed as ‘Cinderella services’ which are nice to have, but not essential. Worse still are
prevailing prejudices about the value of community and patient empowerment. This throws
up a challenge to public health: to be able to explain and describe the central importance of
community empowerment to health improvement; to produce stronger evidence whilst
explaining the fact that social interventions are much more difficult to generate cost-
effectiveness data than biomedical interventions; and to ensure that all funds used to support
patient and community-focused interventions are managed and used well and soundly.

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Chapter 7: The power of information

One of the most important functions of public health is to collate, analyse and use data to
understand the state of population health, as well as the pattern, effectiveness and efficiency
of investments, services and programmes within the health system. This chapter showcases
two recent information capabilities that have emerged as a result of local informatics
developments in H&F in order to illustrate the power of information to improve health and
social care.

Disease registers

One important source of data is primary care ‘disease registers’ which are used to identify and
record patients with specific diseases or conditions. 23 We can use these datasets to estimate
the prevalence of diseases at a population level; and at a local level - patients clinical status;
the quality of care they receive; and their pattern of health service use. Such information is
important for health service planning. We illustrate this using asthma in children as an
example.

As mentioned earlier, analysis of the asthma register indicates that a large number of children
with asthma have not been diagnosed. While the expected prevalence of asthma is 20-25%
among children, only 6.8% of children are recorded in H&F. Under diagnosis of asthma can
lead to recurrent attendances at A&E and urgent care centres where the symptoms may be
diagnosed as wheezy chest infections and treated inappropriately with antibiotics.

The table and map below shows variation of diagnosed childhood asthma prevalence by GP
practice, and the relation between prevalence of diagnosed asthma and use of hospital
services. Some practices have high prevalence of diagnosed childhood asthma and few
emergency admissions for children with asthma, which is an expression of well controlled
asthma. Other practices have a low prevalence of diagnosed asthma in children, but with

23
There are registers for the following conditions: atrial fibrillation, asthma, cancer, chronic kidney disease, COPD,
deafness, dementia, depression, diabetes, epilepsy, heart failure, hyper cholesterolaemia, hypertension, hypothyroiditis,
hyperthyroiditis, ischemic heart disease, peripheral arterial disease, stroke, and TIA.

77
relatively high rates of emergency admission for asthma. Such data can help draw attention to
those practices where there is room for improving care. Collaboration between the PCT,
paediatricians from Imperial Hospital and CLCH has now started to improve the diagnostic
quality and clinical care pathway for children with asthma.

Children 0 – 19 years old with asthma by GP practice

(Source: H&F GP Practice Data, January 2011; SUS)

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Map to show number of Children 0-19 years old with Asthma and prevalence of Asthma
by GP Practice (Source: H&F GP Practice data)

Combined Predictive Modelling

Combined Predictive Modelling (CPM) refers to the identification of individuals who are at
risk of a future emergency admission to hospital. It is based on a formula that combines sixty
pieces of data (e.g. age, disease, previous hospital admissions and medication) which are then
used to calculate a risk for each individual patient. This is done for the entire population
which results in a list of individuals with risk scores ranging from 0 to 100. It is recommended
that 0.5% of the population with the highest risk scores are provided more care and support as
a way of preventing unplanned emergency hospital admissions in the year ahead.

The table below shows the summary results of the output of the CPM run in December 2010
for Hammersmith and Fulham GP registered population.

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 Combined Predictive Model output for H&F in December 2010

If we select 0.5% of population with the highest risks (which corresponds to a risk score of 60
or higher), we would identify 834 people who would need additional support and care to
prevent a future unplanned hospital admission. When we look at these 834 individuals and
examine their past activity, we find that collectively they experienced a total of 2,541
emergency admissions in the previous 12 months!

All GP practices in H&F can now receive a monthly report with a risk score distribution for
their practice population. It should be noted that none of the individuals are identifiable by
name and that patient confidentiality is maintained. It is only the GP that has access to all the
details required to link the risk score to actual individuals.

It is also possible to roughly describe the residential locations of high risk individuals. The
map below shows the rough geographical location of the 0.5% of the patient population with
the highest risk scores for Richford Gate Medical Centre (patient population over 10,000).
Such maps can help GP practices identify those patients at very high risk who may live far
away from the practice for whom additional care and support may be required.

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 Geographical Location of the 50 patients with the highest risk scores registered with
Richford Gate Medical Centre (Source: Ordnance Survey)

It can also be useful for GPs to look at the past health service use of patients with high risk
scores as GPs are not always aware of the frequency or pattern of service usage of their
patients. The following figure (Service User Gram / ‘patient journey’) shows for every patient
how many health service ‘events’ they had over the last year. Every coloured block in the
graph represents an ‘event’. Events related to hospital can be visits to A&E, outpatient
attendances or one or more planned or unplanned hospital admissions. ‘Events’ related to
primary care include consultations with GPs, practice nurse and health care assistants, but
also laboratory results that arrived back to the GP practice, a telephone call or a letter sent out
to the patient; in summary, the GP events give an impression of the amount of primary care
activity going on in relation to that patient. The graph below shows a selection of patients
with very high CPM risk scores and hence very high risk of an unplanned hospital admission
in the year to come.

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 ‘Service User Diagram’ / ‘patient journey’ for people with the highest risk scores
(Source: GP Practice Data; SUS; CPM)

Some practices will have a higher proportion of their practice population with very high risks
compared to other practices. The chart below describes the association between practice IMD
scores and the proportion of the practice population with a ‘very high’ risk of an unplanned
admission. It shows a weak association between the IMD practice score and the proportion of
patients in the very high risk group. Practices in the right upper quadrant have the biggest
challenges while those in the left lower quadrant have the lowest challenge. There is also
likely to be a correlation between the proportion of people with very high CPM risk scores
and the proportion of older people in the practice. We will further investigate this and report
back on the association found.

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Practice IMD scores by the proportion of the practice population with a ‘very high’ risk
of an unplanned admission (Source: CPM; Index of Multiple Deprivation 2007)

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Executive summary & recommendations

This public health report covers a range of diverse topics. Here, we summarise the key
messages from each chapter and propose a set of recommendations. However, the report does
not cover everything related to public health; and a set of additional recommendations are
therefore also listed.

In the next financial year there will no longer be a dedicated Public Health Department in
Hammersmith and Fulham. Rather, there will be a single Public Health Department covering
three boroughs: Hammersmith and Fulham; Kensington and Chelsea; and Westminster. These
recommendations will therefore need to be considered by this new structure.

Chapter 1: Changes and Challenges

The NHS is undergoing one of the most radical shake-ups in its history. This includes a huge
reorganisation and shrinkage of its strategic, commissioning and management structures; the
handing over of responsibility and budgets to GP-led Consortia; moving towards a more
competitive and market-based health system; the establishment of a new national public
health service; and a greater role for local authorities including being responsible for a
number of public health functions. All this is happening at a time of significant financial
constraints across the NHS and other public services. In short, the NHS and local government
are facing a set of unprecedented changes and challenges with far-reaching consequences.

Recommendation 1: Service providers, commissioners and the public should be encouraged to

actively participate in informed discussions about these changes and challenges. Of particular
importance is:
- the setting of priorities and budgets;
- the need to implement change in a way that will optimise the ability of commissioners
and providers to cooperate and collaborate with each other whilst minimising the
negative effects of an increasingly fragmented and competitive health and social care
system; and
- the need to shift resources and attention towards an agenda aimed at preventing
illness.

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Recommendation 2: The Public Health Department, in conjunction with the local council and
GP consortium, should develop a local means of monitoring the impact of the changes and
challenges described as a means of helping to optimise health systems efficiency and health
outcomes.

Chapter 2: Health Inequalities

As with other high income countries, the overall level of health measured in terms of life
expectancy is good in H&F. Life expectancy is above 75 years and compares extremely well
to life expectancy rates of 35 years in many poor countries. However, inequalities in life
expectancy have grown; and there is even greater inequality in terms of the quality of life. In
addition, inequalities in health are not limited to adults: there are considerable and
unacceptable inequalities in child health.

Recommendation 3: While we understand most of the underlying reasons and causes of health
inequalities, the particularly wide inequalities in life expectancy amongst women in H&F are
unexplained and should be investigated.

Recommendation 4: Inequalities in mental health and wellbeing are inadequately monitored

and understood. The depth and quality of data on mental health and well being should be
improved through the production of a Mental Health Needs Assessment in 2011.

Recommendation 5: Inequalities in child health and development need to be given much

greater prominence by commissioners and providers within the NHS and local authority, as
well as by local politicians and community leaders.

Chapter 3: Swimming Upstream

In order to address the problem of widening health inequalities, there is a need to work on the
social determinants of health. In the words of the Marmot Report, health inequalities “stem
from avoidable inequalities in society: of income, education, employment and neighbourhood
circumstances”.

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The Marmot report made a set of recommendations organised around six broad policy areas
(early childhood; schools and education; employment and work; standards of living; healthy
and sustainable places and communities; and ill health prevention). Delivering these
recommendations requires action by central and local government, the NHS, the third and
private sectors and community groups. However, a strong emphasis was placed on local
delivery systems and local government. This report discusses the relevance of the Marmot
recommendations to H&F, and from this the following recommendations are suggested.

Recommendation 6: Ensure that positive early childhood experiences are given greater
priority, especially in light of reductions in the funding of children’s centres and other
services of relevance to young children. A number of actions should be conducted in 2011/12:
- A health impact assessment of the changes made to children’s centres and other
services relevant to young children.
- A local and participatory evaluation of the quality and impact of services provided by
health visitors and midwives in conjunction with CLCH and local maternity services
with the view to maximising efficiencies and promoting continuous quality
improvements.

Recommendation 7: We have little systematic information or understanding about the quality

and impact of school health services. Therefore, a specific school health needs assessment
should be completed, working in partnership with local schools and CLCH.

Recommendation 8: Unemployment is likely to be a growing determinant of poor health that

needs to be mitigated. Of particular importance is the concept of anticipatory care: rather than
treat the depression, alcoholism, domestic violence and smoking-related diseases that can
occur as a consequence of unemployment, it would be better and more cost-effective to
intervene earlier. When individuals become newly unemployed, they should be quickly
identified and provided effective support and advice to avoid or mitigate the negative health
effects of unemployment.

Recommendation 9: In order to make sensible suggestions for how several of the Marmot
Report’s recommendations can be implemented, there is a need to conduct a number of
discrete strategic needs assessments, which would include specific proposals relevant and

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applicable in H&F. The following topics and issues should be the subject of a high quality
strategic needs assessment and review:

- Housing and health

- Unemployment and health
- Climate change and health
- Urban planning and health

Chapter 4: Obesity - More than an issue of fatness

Obesity (and overweight), particularly among children, is one of the biggest unmet health
needs in H&F. It is a marker of poor child care; poor nutrition; low levels of physical activity;
and an unhealthy social and cultural environment. It is a significant cause of the existing
burden of disease and contributes to unnecessary and expensive health care expenditure.
Furthermore, child obesity lays the foundation for a future adult population that will be sicker
and more disabled by chronic disease. Treating obesity is not only expensive but also
difficult. It is therefore a health problem that needs to be prevented rather than treated.

Recommendation 10: Organise a ‘health summit’ in 2011 to discuss, debate and develop an
agenda for preventing obesity. This should involve experts in the field; practitioners,
councillors; and members of the public. It should not be a high profile talkshop; but rather a
moment during which commitment to action is galvanised, and be preceded by several
months of preparatory work.

Chapter 5: General Practice - A platform for more

GP practices and other community-based health services (mainly provided by CLCH) should
form the bedrock of the local health system. By being close to communities and patients, and
by straddling the treatment-prevention divide, primary care providers are also well placed to
advocate on behalf of communities and patients, and to project a holistic and comprehensive
overview of health care provision. There is also no denying the fundamental importance of
the primary care system to the successful achievement of public health strategies and
outcomes.

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However, there are a number of weaknesses associated with the primary care system in H&F.
First, there is an unacceptable degree of variation across a whole range of aspects of primary
care provision. Second, GP practices with more deprived communities generally achieve less
favourable results and outcomes; and appear to be less well resourced. Third, the relationship
that GP practices have with the public health department, CLCH and community
organisations / patient groups is variable and sub-optimal.

Recommendation 11: Reduce variation in the availability and quality of GP care across the
borough.

Recommendation 12: Systematically measure, describe and evaluate the relationships that GP
practices have with public health, CLCH and community organisations / patient groups.

Recommendation 13: Produce an updated version of this chapter of the APHR next year but
with additional information on the performance metrics of CLCH services.

Chapter 6: Putting the Patient and the community centre stage

Communities and patients need to be placed at the heart of the NHS in a number of different
ways and for a variety of reasons. The work that has been conducted in H&F over the past
two years to empower patients and communities is at a critical stage of development and
needs to continue if this investment is not to be wasted.

Recommendation 14: Increase the uptake of the Expert Patients Programme within and
through the GP Consortia.

Recommendation 15: Continue to support and expand the work of Health Champions and
Health Trainers, whilst strengthening the monitoring and evaluation required to assess their
impact and value for money.

Recommendation 16: Start immediately with the development of a plan and budget for the
establishment of a local Health Watch that will be able to monitor the quality and equity of
service provision on behalf of individuals, families and the general public.

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Chapter 7: The Power of Information

One of the most important functions of public health is to collate, analyse and use data to
understand the state of population health, as well as the pattern, effectiveness and efficiency
of investments, services and programmes within the health system. The PCT and Public
Health department have over the last year invested in the development of a single data
warehouse with access to GP, hospital, community, social care and housing data.

Recommendation 17: Increase the awareness of the existence of health and health service
data, and the use of this information across the healthcare sector.

Recommendation 18: Integrate Social Care and Housing data into the current capacity to
analyse health systems performance, and investigate the relationship between Health, Social
Care and Housing data

Other Recommended Activities

A number of critical areas of public health have not been highlighted in this report. These
include the need to continue improving coverage rates for immunisations and adult screening
services for cancer and cardiovascular disease; promoting healthy sexual behaviours
(especially amongst adolescents and high-risk groups); tobacco control; reducing the
extremely high levels of poor dental health in children; tackling multi-disciplinary social
problems such as domestic violence and child safeguarding; improving the knowledge and
capabilities of the general public around medicines usage and compliance; and ensuring
adequate public protection from threats such as infectious diseases.

These issues also need to be tackled in the forthcoming year; and our proposed annual public
health plan includes the following actions:

• Expand the community-based Health Checks programme (screening for

cardiovascular disease);

• Create better demand and mobilisation for breast and cervical cancer screening,
and for child immunisations;

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• Implement a holistic smoking prevention and cessation programme, steered by the
Tobacco Control Alliance;

• Commission an evaluation and analysis of the literature, as well as current

activities and policies in H&F around public mental health;

• Design and introduce an intensive, pilot project on the prevention and treatment of
poor child dental health; and

• Improve physical activity levels through subsidised swimming for children in the
summer months and through a new and innovative project relating to ‘green
prescriptions’

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Appendix 1: Progress on the recommendations
from last year’s annual public health report
Recommendations Progress update

Improve health Since last year’s report there has been the development of a Business
information and Intelligence Unit at NHS Hammersmith and Fulham.
intelligence • This has brought analysts from across the organisation into one team
and promoted joint working across the directorates.
• A data warehouse has been introduced that houses both secondary and
primary care data with potential to also hold community data, social
care data and housing register data.
• Technical implementation of the combined predictive model to predict
likelihood of an emergency admission in the next 12 months for our
registered population. Primary care teams will work with GPs to
actively case manage those patients at high risk.

Borough integration and Joint Strategic Needs Assessment has helped

bridge the gap between health, social care and housing.
• Opportunity to map health data with social care and housing data to see
the overlap in clients.
• Some detailed work on the health and wellbeing of children and young
people in the borough is currently taking place and work on the
importance of housing as a health issue.

Broaden performance As part of annual World Class Commissioning submissions we now

monitoring and provide updates on inequality for our locally chosen outcome measures to
management to go complement the health inequalities indicator (the slope index of inequality
beyond averages and for life expectancy at birth). A number of these outcome measures are joint
routinely include targets for the both the PCT and the Council as part of the Local Area
distributions Agreement. Dimensions that are examined where present in data include:
• Age
• Gender
• Ethnicity
• Geography
• Deprivation levels

Use public and patient Set up a Diabetes Service User Group to work alongside the Diabetes
voice more service redesign group. Service users made decision about the model of
systematically to care, the information on map of medicine, developed a patient charter and
inform commissioning reviewed and questioned the spend on the different elements.
of preventative
services Feedback from users of breast screening services informed the development

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 of a breast screening programme

Feedback from Time of Your Life events together with health champions
informed the development of the Elder Generation (50+) project providing
opportunity for physical activities including yoga, aerobics and women
only classes.

Healthy eating project developed to implement the ‘cook and eat’

programmes that flowed from feedback by service users in White City
Estate. A project using incentives for people to change behaviour has been
developed – DIY Happiness – where participants get £500 vouchers upon
completion of 8 week programme.

A consultation on Dental services told us it would be useful to develop a

wider oral health strategy which allowed for walk in services. We have
now developed a oral health promotion strategy starting with the opening of
new dental services at Canberra Dental clinic.

Over 400 women gave us feedback on a breast screening consultation

which has informed the development of a programme to support GP
practices and patients during their screening cycle.

Health Trainer Programme – The health trainer programme is a national

initiative that enables individuals from disadvantaged communities to adopt
healthier lifestyles through behaviour change. A total of 655 clients have
been engaged since 2008.
• Most clients are either from most deprived or deprived wards in the
borough (78.02%). 51.75% (339) are aged between 26 and 55
years. 91.60% (600) are registered with a GP.
• Clients reported 55.8% self-efficacy improvement of 5%, 20.71%
either achieved or part achieved their personal health plan.
• 20.71% have been signposted to lifestyle risk management
services (12.29%), GP or other primary care services (2.36%),
Emotional wellbeing services (1.02%), among others

Strengthen Robust business cases for preventative services are now routinely
preventative services developed to demonstrate ‘invest to save opportunities’.
by developing business
cases A great example of this is the business case drawn up for the pilot project
for NHS Health Checks in community pharmacies. The project has the
following aims:
• Provide ‘health checks’ in six community pharmacies in H&F – with a
target of 1500 health checks over a twelve month period.
• Link ‘health checks’ to the activities of existing community health
champions and health trainers thereby improving the overall
effectiveness of the health checks programme as well as the efficiency
of health champions and health trainers.

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 • Evaluate the value of conducting health checks in community
pharmacies using this as an opportunity to assess the potential for
community pharmacies to play a broader role in health improvement.

The business case secured the funding and the pilot has now gone live in
five community pharmacies targeting high-risk, hard-to-reach groups.
Once this has been evaluated the aim is to roll out NHS health checks to
community pharmacies across the patch.

Make the most of Kick It Stop Smoking Service (run by the social enterprise Live Well UK
every encounter made up of ex-NHS H&F staff) was awarded the local smoking cessation
between health, social contract and began operating in September 2009.
care and other service
providers and their NHS Hammersmith and Fulham commissioners have successfully created a
patients or clients to contract management framework that balances the need to work
promote uptake of collaboratively with Live Well UK, while allowing them to utilise the
preventative services freedom and creativity which comes from being an independent enterprise.

In particular the preventative service has benefited from:

• a new drop in centre, offering specialist stop smoking advice any time
of the day without an appointment
• clinics in every GP practice bar one and a service in all community
pharmacies
• specialist stop smoking advisors working on a patch basis to promote
the service, liaise with and support GP practices/pharmacies and run
clinics in workplaces and other specialist settings
• the development of a “community” of 100+ locally based stop smoking
advisors who are professionally developed, motivated and rewarded for
their successes
• forward thinking communication campaigns ranging from town centre
lamp-post banners and shopping centre stalls through to text campaigns
and Polish radio interviews

Smoking is a leading cause of preventable death in H&F but for every two
smokers Kick It helps to stop, there will be one fewer smoking related
death in the future – a sustainable investment that will lead to a healthier
population with reductions in health inequalities and fewer patients
requiring expensive medical interventions years down the line.

Use the development The development of polyclinics and polysystems has been disrupted by the
of polyclinics and changes to the NHS. However, there have been clinical workstreams aimed
poly-systems to embed at improving the management of long term conditions in primary care. The
prevention as an service redesign groups for diabetes and respiratory services have included
essential part of all a prevention element. In addition, there have been efforts to strengthen stop
care pathways for long smoking services and cardiovascular health checks in GP practices and
term conditions other sites.

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Create an There are a vast number of fast food outlets in Hammersmith and Fulham
environment in borough. The borough council planning department are committed to
Hammersmith and restricting new fast food outlets opening up within close proximity to
Fulham that promote secondary schools in the borough. This is highlighted in the Local
healthy lifestyle Development Framework and work is currently being undertaken to deliver
choices on this.

However, there are still a number of existing fast food outlets operating
within the proximity of the schools for which the planning department have
no powers to control or influence. Some work is under way between the
PCT and the council’s environmental health department to work with fast
food outlets to support the provision of healthier options to customers, in
particular schoolchildren.

The Hammersmith and Fulham Tobacco Control Alliance formed this year
with the shared vision
• To make it hard for anyone in Hammersmith and Fulham to Start Using
Tobacco
• To make it easy for anyone in Hammersmith and Fulham to stop using
tobacco
• To ensure no exposure to second hand smoke
• To communicate more effectively

Tobacco control involves many agencies, not just health services. These
include:
• Trading Standards to tackle tobacco smuggling and illegal sales,
including to children;
• Local authority environment departments regarding litter and other
environmental issues;
• Schools and other agencies working with children, families and young
people;
• The fire service – cigarettes are still a leading cause of fires;
• Local employers – businesses bear financial consequences through lost
productivity and increased sickness absence among smokers and they
also play a role in helping employees to stop smoking;
• Voluntary sector organisations;
• Other statutory agencies, e.g. HMP.

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Acknowledgements
A number of people have participated and contributed in producing this report:

Alide Petri, Consultant in Public Health

Becky Wellburn, Assistant Director of Primary Care Commissioning
Carole Bell, Programme Director for Children’s Commissioning
Christine Mead, Self-Care Programme Manager
Claudia Farley, Public Health Strategist
David Sayers, Public Health Analyst
Ike Anya, Consultant in Public Health
James Locke, Expert Patient Programme Coordinator
Julia Mason, Maternity & Children’s Commissioner
Katherine May, Public Health Strategist
Kevin Hartzenberg, Designer / Developer
Samira Ben Omar, Head of Engagement
William Gilmore, Public Health Strategist

In addition, we are grateful for useful comments and feedback to an earlier draft that was
provided by various members of the PCT board.

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