Dr John Middleton

1. Recession, Welfare
reform poverty and
health
Dr John Middleton
Director of public Health
Sandwell

8. Reality very different

9. And the peculiar evil is, the less money you have ,
the less inclined you feel to spend it on wholesome
food. A millionnaire may enjoy breakfasting on
orange juice and Ryvita biscuits; an unemployed
man doesn’t
When you are unemployed, which is to say when
you are underfed, harassed,bored, and miserable
you don’t want to eat dull wholesome food……
George Orwell, The Road To Wigan pier.

12. • Harvey Brenner Int Journal Epidemiology
• 2005, 34, 6: 1214

13. Recession and policy changes
Health impacts of economic downturn
• Widening health inequalities
• Worse mental health –including depression, and possibly
lower levels of wellbeing
• More suicides and attempted suicides;
• Possibly more homicides and domestic violence
• Fewer road traffic fatalities
• Worse infectious disease outcomes such as tuberculosis
and HIV

16. Male life expectancy at birth, local authorities 2008-10
Life expectancy
(years)
86
84
82
80
78
76
74
72
70
0 30 60 90 120 150
Local authority rank - based on Index of Multiple Deprivation

17. Young people not in employment, education or training (NEET), local authorities
2008
Not in education
employment or training
%
14
12
10
8
6
4
2
0
0 30 60 90 120 150
Local authority rank - based on Index of Multiple Deprivation

18. 18

19. Changes in real income for each 10% band of
population, 1979 -1991/92, after housing costs
Percentage
10% (Poorest) -17
20% 0
30% 6
40% 16
50% 23
60% 29
70% 33
80% 39
90% 46
100% (Wealthiest) 62
-20 0 20 40 60 80
Source: Households below average income 1979-1991/92, Department of Social Security (1994)

20. Why ‘Child’ Poverty?
Isn’t all poverty something we want to address?
Source: The poverty site http://www.poverty.org.uk/09/index.shtml

21. Child poverty means family poverty
• 1 in 3 children in Sandwell live in relative poverty. This
means approximately 24,000 children
• Of the 40,580 families with children dependents in
Sandwell in 2008, more than 95% were in receipt of
Child Tax Credit (CTC) or equivalent.
• For every 10 families in Sandwell receiving CTC, 7 were
in work and 3 were out of work. The distribution of
worklessness matches well-known patterns of
deprivation.
Child Poverty Statistics, HMRC 2009

23. 23

24. Life expectancy & disability free life expectancy at birth,
by neighbourhood income level, England and Sandwell 1999-2003
Age
Neighbourhoods by income deprivation (population
percentiles)
24

26. Sandwell, Deaths by Coronary Heart Disease Sandwell, Deaths by Coronary Heart
(CHD) ICD10 Disease (CHD) ICD10 I20 – I25 (5
I20 – I25 (5 year rolling average) year rolling average) Mortality
Directly Standardised Mortality Rate, Total Rate, Population Aged Under 65 Years
Population Directly Standardised
Wednesbury
Wednesbury Wednesbury
Wednesbury
North
North Friar Park
Friar Park North
North Friar Park
Friar Park
Great Barr with Yew tree
Great Barr with Yew tree Great Barr with Yew tree
Great Barr with Yew tree
Charlemont
Charlemont Charlemont
Charlemont
Wednesbury
Wednesbury Wednesbury
Wednesbury
Princes End
Princes End with Grove Vale
with Grove Vale Princes End
Princes End with Grove Vale
with Grove Vale
South
South South
South
Hateley Heath
Hateley Heath Newton
Newton Hateley Heath
Hateley Heath Newton
Newton
Great Bridge
Great Bridge Great Bridge
Great Bridge
Tipton Green
Tipton Green Tipton Green
Tipton Green
West Bromwich
West Bromwich West Bromwich
West Bromwich
Greets Green Central
Greets Green Central Greets Green Central
Greets Green Central
and Lyng
and Lyng and Lyng
and Lyng
Oldbury
Oldbury Oldbury
Oldbury
Tividale
Tividale Tividale
Tividale
St. Pauls
St. Pauls St. Pauls
St. Pauls
Soho and
Soho and Soho and
Soho and
Rowley
Rowley Smethwick Victoria
Smethwick Victoria Rowley
Rowley Smethwick Victoria
Smethwick Victoria
Langley
Langley Langley
Langley
Bristnall
Bristnall Bristnall
Bristnall
Blackheath
Blackheath Blackheath
Blackheath
Abbey
Abbey Abbey
Abbey
Cradley Heath
Cradley Heath Cradley Heath
Cradley Heath
Old Warley
Old Warley Old Warley
Old Warley
and Old Hill
and Old Hill and Old Hill
and Old Hill

27. The Marmot Review
• The best evidence for
what we need to do
• The biggest influences on
health & wellbeing are the
‘social determinants’ of
health
• The ability to influence
these sits largely with the
local authority
27

28. • Reducing social inequalities: UK Marmot
review
• Early years education and family support: increase % spend in early
years
• Evidence base: Family nurse partnership
• Perry preschool study
• Triple P parenting
• Surestarts and Childrens centres

30. • Educational attainment is a
predictor of health outcomes.
• Higher educational attainment
is associated with healthier
behaviour.
• There is a gradient in limiting
illness by level of educational
attainment.
• There is a gradient in mortality
by educational attainment.
Education and Skills

31. Children achieving a good level of development at age five, local authorities 2011
Good level
of development
at age 5
%
80
75
70
65
60
55
50
45
40
0 30 60 90 120 150
Local authority rank - based on Index of Multiple Deprivation

32. • Reducing social
inequalities: UK Marmot
review
• Maximise the capabilities and control
young and adults
people have over their lives : reduce the
social gradient of skills and
qualifications

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

34. Work is good
 More than just a source of cash
 Psychological and social benefits
 Structures people’s days
Not working affects life
expectancy
 Should be rewarding and
fulfilling
(Marie Jahoda)

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

36. Sandwell welfare rights
services

37. 37

39. How unemployment influences health
Material and psychosocial effects, can lead to:
• an inability to afford to live a healthy life
• distress, anxiety, depression and a
worsening of physical health
• a loss of self identity and self esteem
• an increase in smoking and alcohol
consumption and decrease in physical
activity.

40. Employment and Life Expectancy
• Those experiencing unemployment are likely to have higher mortality rates over
their next decade, than those working.
• Mortality rates are higher in manual compared to professional professions.

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

45. Green Space

46. Green Space
Greener living environments: lower
health inequalities, England
Deaths from circulatory disease
Income group 4 is most deprived
Source: Mitchell & Popham, Lancet 2008

47. 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

48. Housing and Health

49. Achievements so far
Service Investment Estimated annual
savings to NHS
Health Homes Advocate £30,000 £44,800
HUB £7,000
Handy Person Service £100,000 £132,000
Affordable warmth £250,000 £105,000
Home improvement agency £25,000 £56,000

51. • Reducing social inequalities: UK Marmot
review
• Strengthen the role and effect of prevention of ill health priority for
investment to reduce social gradients-

52. Breakdown of life
expectancy gap by
disease for males and
females, Sandwell (DH
Health Inequalities Tool)

53. CHD Mortality 2000-2005

54. Male life Expectancy at birth, Sandwell and England
79.0
77.9
78.0
Life Expectancy (Years)
77.0 Gap:
3.4
years
Gap: Gap: Gap: Gap:
76.0
2.5 2.9 3.5 3.6
years years
years years Sandwell
75.0
England
74.0
74.4
73.0
72.0
2003-05 2004-06 2005-07 2006-08 2007-09
3 year periods
54

55. 55

56. Three dividends for a healthier future
The health dividend

57. Domestic burglary Sandwell 2001-
2005 Full implementation
drug intervention
project doubling
numbers of drug users
in treatment
1300 fewer
domestic
burglaries
33% fall

60. Three dividends for a healthier future
The inclusion dividend

61. The Future?
 Easy to use Patient
Graphic interface
 Wireless or wired devices, POTS and IP Communications
 Software based product – operates on a variety of
devices in expanding applications
Tablet PC CareCompanion II Handheld devices
 Standard protocols – easy
customization

62. i- House,
demonstrationhouse West
Bromwich 2008

63. Three dividends for a healthier future
The green dividend

65. Good corporate citizen award
38 apprentices
Rationalisation of offcies : 6
leases surrendered
890 tonnes of CO2 reduction
£200k saved

66. Citizen Wage?
 Time to resurrect the concept
 Recognises work not covered by
the conventional economic system
 Advantages to employers and
industry

67. Everyone’s business!
• Consider health impact of
our activity
• Read the Public Health
Report
• Read the Marmot Review
summary
• Visit Sandwell Trends
www.sandwelltrends.co.uk
67

68. • THANKYOU
• John Middleton
• Director of Public Health for Sandwell
• John.middleton@sandwell-pct.nhs.uk
• Vice President, UK Faculty of Public
Health
• vpPolicy@fph.org.uk