1. Public health white
paper 2010
The ‘life-course’ approach
• Early years
• Start well
• Working well
• Living well
• Ageing Well

2. • Reducing social inequalities: UK
Marmot review
• Early years education and family support: increase %
spend in early years
• Maximise the capabilities and control young people have
over their lives : reduce the social gradient of skills
and qualifications
• Create fair employment and good quality work for all and
improve quality of work across social gradients
• Ensure healthy standard of living for all reducing the
social gradient through progressive taxation and other
fiscal policies
• Healthy and sustainable physical environments
• Strengthen the role and effect of prevention of ill
health priority for investment to reduce social
gradients

3. • Reducing social inequalities:
UK Marmot review
• Early years education and family support: increase
% spend in early years

5. “Changing the world – one baby at a time”

6. Trials of the NFP
in USA
Elmira, NY Memphis, TN Denver, CO
1977 1987 1994
N = 400 N = 1,138 N = 735
• Low-income • Low-income • Large portion
whites blacks of Hispanics
• Semi-rural • Urban • Nurse versus
paraprofessio
nal visitors
6

7. Consistent results
across 3 trials in USA
• Improvements in women’s antenatal
health
• Reductions in children’s injuries
• Fewer subsequent pregnancies
• Greater intervals between births
• Increases in fathers’ involvement
• Increases in employment
• Reductions in welfare dependency
• Reduced substance use initiation
and later problems
• Improvements in school readiness
Program effects greatest among
those most susceptible
7

8. Evidence for early years support
Perry Preschool High Scope study
Abercedarian university study
Cochrane review of early years and family
support for deprived communities
6 sound studies review of Harden, Oakley et
al BMJ 2009

9. Program No program
Did homework at age 15
In program for mental impairment
IQ at 5 90 or more
9th %ile or better in school at 14
Average or better literacy at 19
0 10 20 30 40 50 60 70
Data from the High/Scope Perry preschool project. Bars represent percentage in each of the
two groups. The difference in major educational performance findings between program and
non-program children is significant.

10. Program No program
5 or more arrests by age 27
Soc.Services ever in previous 10 years
High school graduate
Home owner at age 27
$2000 or more monthly pay
0 20 40 60 80
Further data from the High/Scope Perry preschool project. Benefits from the program
continue to be seen in adulthood. Bars represent percentages of each of the groups The
difference between program and non-program children is significant.

12. • Reducing
social
inequalities:
UK Marmot
review
• Maximise the
capabilities and
control young and
adults
people have over
their lives : reduce

13. • Reducing social inequalities: UK
Marmot review
• Create fair employment and good quality work for all
and improve quality of work across social gradients

14. • Reducing social inequalities:
UK Marmot review
• Ensure healthy standard of living for all
reducing the social gradient through progressive
taxation and other fiscal policies

16. • Reducing social inequalities:
UK Marmot review
The spirit level -
Richard Wilkinson work looking at how the
more equal societies are invarialy
healthier, happier, more free of crime,
better achievers with lower unintended
pregnancy rates and other adverse social
indicators

17. • Reducing social inequalities:
UK Marmot review
• Healthy and sustainable physical environments-

18. Supportive environments - safe routes to school

19. Increasing the supply
of healthier food in
Sandwell
From this….

20. ….to this

22. By 2003 the mixed use site was in production…

24. Increasing
the
production
of
healthier
food _
Sandwell
community
agricultur
e strategy

25. Making it Happen
Editorial
“The challenge is to make
politicians work for an
environment that
promotes walking, and to
call on doctors to
encourage patients to
walk…”
BMJ 9th June 2007

27. Healthy towns-Sandwell
Healthy Urban Development
Unit
Outcomes
• Healthy urban
development approach
• Working with town
planners and transport
engineers – to influence
policy and design
• Emphasis on environment
and open spaces- create
safer places where
people
• Encouraged to walking
and cycling
• Health impact assessment
on all developments
• Spin off for comments
on health care impacts
eg new nursing homes

31. Reducing social
inequalities: UK Marmot
review
• Strengthen the role and effect of
prevention of ill health priority
for investment to reduce social
gradients-
will discuss in relation to NICE
guides

32. Reducing the
social gradient
through
targetted health
promotion
• Cardiovascular
disease
identifying
people at risk

33. Implementing effective interventions :
NICE public health guidelines
Cardiovascular disease identifying
people at risk
Communities for health Sandwell model
• Nurse led programme of CVD risk
management for patients at> 20% risk
of heart attack in 10 years
• Health trainer intervention for
those >15% risk
• Universal advice and information
service via community organisations
for general population at lesser risk

34. Sandwell CVD risk reduction model:
projected benefit
Sandwell Eligible CVD Events
for prevented over ten
treatment years
Aspirin 11,382 410
Antihypertensive 6,860 288
therapy
Statin 11,694 947
Total 1,645
Total if attendance 1,020
same as for pilot
If 30% of 494 based on
circulatory events eligibility
result in death, 306 based on

35. Martin Bobak about the catastrophic
rise in death rate in Russia in
1990-1995 due to destruction of
Soviet economy
Will western countries under
austerity measures be spared extra
deaths?
Stuckler and McKee argue that social
welfare spend should be preserved in
times of recession and reduced in
good times.
WHO have argued health investment is
protective for national economies
(Brundtland 2000,susana 2010)

36. The Changing landscape for public health in England, John Middleton Warrington,
March 2nd 2011
Public health – a role
for councils

37. The Changing landscape for public health in England, John Middleton Warrington,
March 2nd 2011
Civic Pride
That the people I represent die younger
than people in other parts of the country is
not acceptable –
That the people in one part of my area are
dying younger than others is unacceptable

38. The Changing landscape for public health in England, John Middleton Warrington, March 2nd
2011
Sun cream, health fairs and pest control ?
Or :
Housing and excess winter deaths,
Air quality and heart disease,
Traffic congestion and walking to school
Fear of crime and lack of exercise ?
Littering and obesity ?

39. The Changing landscape for public health in England, John Middleton Warrington,
March 2nd 2011
The inverse care law:
‘People who need the most health care
get the worst, and the poorest quality’
‘Poor people get poor services’

42. Thank you
John Middleton
Director of Public Health for
Sandwell
John.middleton@sandwell-
pct.nhs.uk
Vice President, UK Faculty of
Public Health