Public Health

An investment strategy for population health (1)


Healthcare is eating other public service funding so says the ex editor of the BMJ. This blog from Mathew Whittaker sets out how the austerity policy and political priorities pursued by successive governments have placed major strain on a number of public services. He argues that, as a result, the size of the state has changed over the past decade and so too has its shape.

“Local government budget is on course to have been cut by 77% in 2020-21 relative to a 2009-10 baseline when measured on a per-capita basis. Other departments have fared only a little better, with real-terms per-capita spending down by a half in Housing and Communities, Transport and Work and Pensions, and by a third in Scotland, BEIS, DEFRA and Justice.” 


It is worth noting the changing proportions of government spending to “health” (the NHS) out to 2070.

The IFS analysis of local government spending highlighted broadly the same story. Of course it was an analysis of local government thus included locally raised revenue. Thus the numbers look different. Statutory services have (rightly) been relatively protected. Non statutory functions, of note include many of the place shaping and regulatory functions, have not. One might only wonder what impact this has on our health. As a colleage of mine once pointed out, the services that we have cut furthest are basically the social determinants of health.



We know from plenty of analysis (IFS / NEF / JRF to name a few) that recent changes in spending and welfare have disproportionately disadvantaged those who are more vulnerable – at individual, family, community and city level.

Smith pointed out that overall health care accounts for about 7% of the economy, that proportion having doubled over 40-50 years, pensions for 5%, and social care for 1%. In terms of public expenditure, spend on NHS  has increased from 25% of public expenditure to 40% in last 20-30 yrs I had posted a thread on the “hegemony of health” a while ago. On past hisotry, the ever increasing spend on “health” (by which most mean the NHS) isnt set to deliver more “health. It simply displaces other investments that have a greater impact on health (and the may dampen ever  increasing demand for care). The crowing out is self accelerating. Back to my opening statement, health care expenditure is eating other public service spending. It is easy to argue that disinvesting in what actually generates health lead to preventable misery and spiralling healthcare costs? As has been pointed out “A national, natural experiment (ethics pending) “


Wanless told us this 20 years ago, everyone ignored him. Not addressing this will simply lock in ever upward spiraling % of GDP devoted to NHS.

There IS a need to reframe. “health” and “health inequalities” seem enduringly “stuck” as an NHS issue, or at best an issue that not (only) will be solved by better or more health care services whilst the narrative is often (usually) in the right place nobody is making investments in “the determinants” of health.

Within the NHS the powerbase and resource base is set all wrong for optimal population health between the NHS and wider potential investments the resource and powerbase is also set wrongly for optimal population health. There are distortions in resource distribution & attention that over prioritie process indicators over population health outcomes, & hospital-based care over prevention, community & primary care.

This isn’t good for our health, I would encourage you to read health economics 101, especially about opportunity cost and the law of diminishing marginal returns. Again, Richard Smith set this out 6 years ago as did Don Berwick who was then in charge of the worlds largest health care system. The three most important things that health economics can give us are those or opportunity cost, the law of diminishing marginal returns and incremental cost effectiveness analysis. We are VERY good at ignoring all of them.

This is all good news if you’re in med tec not so good news if you actually want substantial population health improvements.

Unchecked, the future NHS budget will be enormous – this isn’t necessarily good for our health and simply sets up a self fulfilling cycle. Of course that matters for social care and NHS demand. Wanless eloquently demonstrated this two decades ago (we ignored him….). It also matters to economic productivity, I have posted some comment on this one already  and there is more to follow.

Any serious attempt to improve health has to engage with this, whether locally or nationally. It has to be a truly cross government affair, not something that starts with the NHS and never quite gets out of that, and we should put our money where our mouth is






Public Health

Councils Can be trusted with Public Health

Councils Can be trusted with Public Health

This is an extended version (for the public health dorks and nerds) of a piece which appeared in LGC . Thanks to LGC for permission


Jim McManus and Greg Fell


Jim McManus is Director of Public Health for Hertfordshire and Vice-President of ADPH. Greg Fell is Director of Public Health for Sheffield and Hon Secretary of ADPH.


Much of those bits of Public Health that were in the NHS have now been back in local government in England since 2013. The Health Select Committee acknowledged evidence from Public Health England that 80% of outcomes for which local authorities were responsible either stayed the same or improved despite significant cuts to public health[1].   The Local Government Association and County Councils Network both published reviews of how local government had delivered on Public Health.  The Select Committee report on Sexual Health and the Government’s own review in 2019 both concluded there was no case to move commissioning away from Councils.


This week sees another, independent, report speaking into this field. The King’s Fund report The English Local Government public health reforms: an independent assessment[2]  The report assesses the transfer of public health to local government and reaches a number of important conclusions:


  • Public Health Directors and their teams are well embedded and have helped make councils the home of prevention
  • Strong links have been formed with different council departments, outcomes across the vast majority of indicators are good and there are widespread examples of innovation
  • This is against the backdrop of significant cuts to local government and public health specifically; as well as other key areas of spending like welfare, early years and criminal justice
  • The report says there is a cllear agenda for the 2020s – focusing on keeping performance and outcomes strong, working council-wide to shape healthy places and continuing to improve collaboration with the NHS and other partners
  • The report says that to achieve improvements in public health, the Government must increase spending with a long-term settlement and develop a coherent policy agenda to address the social determinants of health and wellbeing across Whitehall departments


The report systematically looks at what has been achieved and builds on earlier reports, reviews and studies. And it’s independent. There are some crucially important lessons from this report.


First, the transfer was about much more than lifting and shifting a bunch of services.   The King’s Fund points out that the Government itself said in 2010 that “to… avoid the problems of the past, we need to reform the public health system. Localism will be at the heart of this system, with responsibilities, freedoms, and funding devolved wherever possible.” The Public health reforms “had a wider purpose, for public health teams to influence and support wider local government decisions that impact the public’s health.”  Our health starts and ends way beyond the walls of hospitals and clinics – the education we get, the places we live in, the amenities we can enjoy, the work we can earn from and the environment we live in are all crucial. These are the areas where councils can influence. And the report concludes “the move to local government for many public health services was the right one. More important still, in the long term is the opportunity this has to influence wider local government policy and decisions; now is the time to make good on the opportunity in the context of the development of place-based population health systems. “


Second, there was undoubtedly a job of transformation to do on some services. This has undoubtedly been difficult for some and hard work for all. The Economist[3] in May 2019 reported that sexual health, largely because of the burning platform of significant government cuts to the public health grant against burgeoning demand, has been the sector of health care which has perhaps seen most innovation in the last six years. Where that has worked that has been down to local authority commissioners and provider partners working together. The Economist concluded this probably would not have happened at the same scale and pace in the NHS.  The narrative that all was fine in the NHS was simply not true, however great the NHS is.  We all – from whatever sector – need to improve.


Third in my view comes the issues of connections and systems approaches. Most public health services have far more links with council services than they do with other NHS services. Health Visitors and School Nurses, for example, are now working in integrated early years or young peopes’ services in many areas.


None of this is saying the cuts to public health were a good thing. Quite the opposite. While they forced innovation, they undoubtedly had consequences. The report itself says that the transfer cannot be considered in isolation to the cuts…and that the reforms led both “to significant innovation” but “ there has been some fragmentation of commissioning and provision, particularly in those service areas that are interlinked with NHS provision, for example, sexual health, and drug and alcohol services.”


So we now have a series of reports and reviews, this being the most systematic, which concludes the transfer was broadly right. Ever since the transfer we’ve had a slowly declining number of commentators and agencies – who have never tired – despite lacking any decent evidence – of lining up to say the transfer was a mistake, everything was better before 2012 and using the words of one national organisation, called for the “failed experiment in commissioning” to end. This report has already invoked the noise of those who will never be happy until someone they agree with concludes we should send it all back to the NHS.


This report confirms my resolve to give them no more air time. Despite the cuts, this report shows their calls have missed the point, and it would be folly to heed their counsels of despair.


Significantly, the King’s Fund in 2019 joined forces with every major Health Think Tank and over 55 national health charities and expert bodies calling for Government to reverse the public health cuts and invest in Public Health. And its report concludes that “the reforms, however, coincided with austerity where local government funding, in the specific public health grant and more widely, was not prioritised by the government compared to NHS funding, receiving real-terms cuts from central government. There now needs to be an increase in funding from central government, at least an additional £1 billion for the public health grant every year from 2020/21, to keep pace with population growth and inflation. “


The question we should all be asking ourselves now is how do we truly gain the most benefit this report can give us? I suggest four priorities here:


First, I call on everyone to join the growing number of national leaders calling for government to recognise the good sense of investing in public health (and in local government services more widely) as essential to achieving a healthy population. This report must be an impetus to renew this coalition for public health funding.


Second, while Public health teams have integrated well into local government, there remains much opportunity to influence economic development, growth and planning. Being in local government is no easy ride given austerity. But if we want to influence wider determinants – and any public health professional who doesn’t needs to ask themselves why they are still in public health – then local government remains the primary place to be.


Third, the impetus for improvement, to do better. The report says that now the reforms are embedded “ more attention now needs to be paid to outcomes and tackling unjustifiable variation. More effort is required to understand how local government public health efforts change population health outcomes including: understanding the contribution to change in complex systems; benchmarking and productivity between local areas; and more effort by the National Institute for Health Research and others to support evaluating practice ‘on the go’.” STPs and ICSs should be taking this every bit as seriously as local government.


Giving local government every chance to succeed features strongly in this report. That ranges across ensuring future funding mechanisms do not “unintentionally put public health spending and outcomes at risk” to calling for Public Health England to “do more to support local government to define, diagnose, and tackle unjustifiable variation in practice and impact on population health outcome”. The leadership role of Directors of Public Health and their staff “will be critical in shaping successful place-based population health systems. “ Are councils really using this to best effect?


Finally, there remains an opportunity to rebalance effort across the system. The report says “there are opportunities for a greater focus on prevention in the NHS long-term plan and the government’s prevention consultation paper. But the NHS and central government need to ensure that these changes are consistent with the wider context, a shift to place-based population health systems, where local government is a key player. “ There were some in previous reports who bemoaned the loss of public health from the heavy clinical focus it certainly had in several NHS roles I worked in. What the King’s Fund makes clear is that rebalancing to ensure we address place and wider determinants and reduce the dominance of the clinical focus we had within the NHS is right.


I don’t agree with everything this report concludes. Health and Wellbeing Boards remain hugely variable in their influence, leadership and impact and I think the King’s Fund is too uncritical of the way population health management discourse risks creating a too strong emphasis on individual clinical preventive interventions, creating a clinical model of prevention the NHS can understand but the record of unwarranted variations over thirty years shows it is not great at tackling. But it would be a huge mistake if this report didn’t influence policy making across Whitehall and across local systems.














Public Health

Is there any *actual* evidence for social prescribing yet

Is there any actual evidence for social prescribing yet?


…..I was asked recently. In fact it’s a q that crops up a lot


My immediate answer is normally –

1) yes,

2) define social prescribing,

3) define “work”,

4) its tricky,

5) apply a level playing field, and a lot of common sense.


My previous thoughts on evaluation in this thread.. Here I unpack it a bit more


1          What evidence IS there

A cynical (or pragmatic?) view would be that a “roll out” has shades of many other schemes that get rolled out …. Seems “intuitively a good idea but rolled out without proper resourcing or evaluation”. The former is definitely true.


With regard to the latter – It is CERTAINLY a concept that is under evaluated as the Bickerdike “rhetoric v reality” paper aptly demonstrates. What we have in terms of research based is a fairly wide set of smallish scale, shortish term studies, often not published in peer reviewed journals.

There are plenty of stuff out there. I wont re rehearse the evidence base here.


The evaluation of part of the Sheffield scheme is here c /o @JanetHarrisShef. It focused on the “link worker” bit (for us called Community Support Workers). Arguably this is the EASIEST bit of the SP sytem to research outcomes and impact. It wasn’t that easy. Getting the data sorted for all this was a royal trauma we did our best. The evaluation looked at the feasibility and utility of a city-wide, brief intervention provided by community support workers to link people with non-medical issues to a range of services


The best quant analysis I ever saw was Luke Munford – talk here, paper here. @SoadyJohn in my team told me at the time that “Luke nailed it”. John is very battle hardened. If he is happy methodologically Im not arguing with him. Key points – a) Participation in community assets is associated with substantially higher HRQoL but is not associated with lower healthcare costs once obvious confounding factors were controlled for, b) based on a threshold value of £20 000 per QALY, the net benefits of participation in community assets were £763 per participant per year, c) there is some interesting stuff (IMO) on demand shifting in the results section also


Developing the evidence base – Does anyone want to invest in big studies?

TBF few seem interested in funding robust evaluations

obviously there’s no commercial interest as there aren’t gizmos or drugs with a name ending in “mab” involved

this is exacerbated by commissioners having no funding to commission such research and / or don’t see it as their role to fund “proper” research.

There are multiple programmes of work being undertaken at the moment to improve the evidence base and develop a common outcomes framewor. This is work in progress and something to be hopeful we will get the right note from it. The evidence for the types of intervention that SP links people to is relevant here – mostly with physical exercise and the benefit of programmes that combat loneliness and social isolation. We should be looking beyond the mechanism – there is no evidence for a paper prescription after all, just for the drug that is at the end of it.



2          However, there are a number of important buts in sorting out a robust conclusion on whether there is (or isn’t) any good evidence base supporting this field


  1. a) What IS social prescribing, boundaries

agreeing what the intervention “is” seems not uncontested.

The name remains problematic for many. It is not a term the NHS has actively created (building on work in Bromley By Bow – Everington / Mike Dixon and similar). The term SP has legitimised “social” as an intervention for the NHS, that is helpful in itself. The recent NHSE push is trying to find the sweet spot between medical model and full on ABCD, and provide a mechanism for NHS frontline staff to engage in what for many are called the “social determinats of health”, this seems a good thing. The aim is to systematise and scale it. We all know we need to take care re not about over medicalising or creating a paternalistic structure…. or simply a signposting service. We all know employing a link worker in itself does not constitute social prescribing, and that the concept would not exist without local councils/ Vol sector. It happened for decades without NHS

The blog by @BeckyMalby is excellent – 3 things you should know about social prescribing: – a) Don’t add Social Prescribing on as another project. b) Get out of the way. An asset-based approach generates masses of gifted time, energy, care and compassion. It’s not a service. c) When it works its not a service add-on; it’s a whole way of relating – redefining roles in the practice and re-shaping the way professional relate too and with people in communities. d) count friendships.


Actually putting a definable “boundary” on the thing called social prescribing varies massively from place to place, and varies according to our beleifs, world views, who the funder is and whether funding is small and short term or more structural and long term. SP often misses (in my experience) big areas where there is good evidence of impact. For example a) physical activity (notwithstanding some very important wrinkles in the evidence of long term impact of exercise on prescripotion narrowly constructed), b) arts and culture See this recent WHO report and this helpful BMJ blog and c) welfare advice often don’t seem “included” in social prescribing.


What is now being called social prescribing has existed for considerably longer than the NHS has, and it is testing the boundaries of an asset based working v deficit model. It will be important to nail the opportunity to properly engage local government, communities & voluntary sector & genuinely relocate some authority and resources. It will be important to miss the opportunity, the NHS is clearly signalling that increasingly it sees “social” as a valid intervention when social is what is needed, not clinical. It is fair to say that the NHS is catching up. The £0.5bn NHSE investment in Link Workers over 5yrs is helpful but we all know (inc within NHSE) that link workers alone are not sufficient. It is reasonably that if NHSE do some investment there should be some investment to come from CCGs / local authorities. If NHSE make investment it is reasonable there is quid quo pro, and it is unreasonable that CCGs and local authorities see this as a reason to disinvest from the cutrrent funding. Of course it is a given that funding for all is exceptionally tight. Nothing comes for free.


Does / should the “evidence base” for social prescribing cover the notion of community development per se, link workers (between NHS or other statutory settings and community based assets) or interventions delivered. Or all of the above. To my mind there is a lot of muddled thinking on whether “social prescribing” covers some or all of these, and we probably all think about it differently.


Social prescribing (or whatever you want to call it) doesn’t exist by itself. Asset based approaches are not new they are well established and we are well and we are continuing to build. Asset based community development is a precursor to the success of community infrastructure, which is a precursor to the success of what many now call social prescribing. We should think carefully on this and shift away from investing in activity towards investing in a community and an infrastructure. If we only invest in activity quite narrowly than the added value and spin-offs are lost.


  1. b) Paradigm of evidence

There is a classic biomedical paradigm meets social paradigm territory. This makes it very very tricky methodologically. We should be careful on the use and misuse of evidence in this one. I have blogged a lot on this one – see this blog series on the use and misuse of evidence in “public health” (term used advisedly). Esp blog 4 – special cases.

We often, in my experience, have woefully inadequate thinking around “evidence” in complex social paradigms, or an inadequate understanding conceptualization of what they label as SP.


This matters when asking questions about “what does the evidence say”!



  1. c) What outcomes, what impact, return on investment and a level playing field

I’ve consistently been of the view we need to be exceptionally careful to avoid getting into expectations and asks of what we now call SP.


And, of course we all want a nice, neat, clean and simple evidential answer on “impact”, or the answer to the “what outcomes will it deliver” question. The neat clean answer doesn’t exist. There is a similar thing to be said about say General Practice. As a perhaps inflammatory example, consider this study testing using patient centred models for those with multiple long term conditions. The abstract of the study clearly says it made no difference. The subsequent cost effectiveness study said it wasn’t really a cost effective intervention (no surprise looking at the original study).


But, I don’t hear many arguments for abandoning patient centred models. For what it is worth, I think that the interpretation of this study should be far more nuanced than the last line in the abstract – a story for another day!). To me, measurable “impact” (especially in a way that might make finance teams happy) seems largely an exercise in impossibility given the nature of the system SP operates in.


There is something to be said here about level playing field around the statutory sector  vs VCS (we all know the stat sector often make VCS sweat a lot about small short term contracts and outcomes, but really don’t know what outcomes we get for the £billions we put into many clinically oriented areas.


There is also something about NOT seeing investment in vol sector as only a mechanism for “managing demand for NHS and social care”, or worse “reducing admission to hospital”. If that happens then a) its fabulous, b) it’s a happy bi product of an intervention c) there it’s a bi product of the intervention or service under consideration or whether some broader construct. Demonstrating links and attributability is probably impossible.


We don’t have the sophisticated methods to be able to demonstrate it…. the evidential smoking gun from service to impact. There Is some merit in mapping out some form of logic model…. but to really get from intervention to impact is probably impossible given all the other things that are also going on in that system.

This takes us back to the level playing field concept.


I’m not saying that outcomes don’t matter!. Getting the right approach to “outcomes” remains an important deal. Of course it remains important to be practical and prammatic on the extent to which we have an expectation of demand shifting or money saving, especially the ability to measure and attribute this in the complex system social prescribing operates in.  .

NHSE have set out what is proposed as a common outcomes framework (see p28). On “outcome measures” I went to an excellent event a few weeks ago on how to best develop outcomes. The notes and live scribe illustrations here.  There is a need for a sensible discussion about proportionality here. We don’t ask statutory sector to collect large volumes of outcome data from every GP appointment or outpatient clinic. Whether we use data for outcomes / monitoring / simply celebrating what is good and happening / or research. We also discussed that if we collectively want “outocmes” data we will have to invest (probably quite heavily) in infrastructure to enable it to be collected, and skills development in VCS orgs and the statutory sector to enable different stakeholders to use it and to engage with it. The search for a single outcome measure to bind them all continues. Personally I don’t think it is that helpful, or at least it is probably a futile search. Finally the workshop had an interesting conversation about whether we should be collecting outcomes at individual level or whether we should focus on groups and places.


We SHOULD expect there to be some well being benefit, back to the Munford study. Factoring these things into our evidence building model will be important. Then we get into what people want to / choose to believe in, that’s tuned according to our prior beliefs etc. I will settle for carefully thought through logic model, with well thought through process outcomes related to the service per se (are they delivering what they said they can deliver) rather than end user outcomes or outcomes expressed in terms of demand on other downstream services

So for example our scheme in Sheffield (called People Keeping Well) operates in a complex space – far broader than say “primary care” (as defined medically). But when someone wants to know what “outcomes” are delivered from SP, I often ask what “outcomes” are delivered by primary care, or social care, or even renal or cardiovascular care (though the more specialised we get the more easy it is to have a good stab at outcomes. For cancer – 5y survival or better site specific mortality, but for an entity that is rather more diffuse it just doesn’t work.

For example this modality of intervention doesnt exist to saves “health” cashable savings if that happens then its a very happy bi product it probably wont be seeable, countable, never mind cashable.

On the concept of return on investment, this thread by @harryrutter is excellent. There is a lot of salient advice in this on ROI!


On opportunity cost

I would like to draw the readers attention to the cancer drug fund, I have lost count on number of drugs ending in nib or mab that NICE approval based on questionable economics, Proton Beam Therapy, Avastin in ophthalmology (of note NHSE largely silent on this), robotic surgery. I could go on, and on. There are many £bn tied up in these interventions of marginal (at best) benefit with significant opportunity cost. So lets have a level playing field on the impact of SP please!

  1. d) Funding

Finally on funding there remain big challenges with a fully funded model, imagine if there were a tariff for the activity that people are enabled to access in the same way there is a tarrif for a rheumatology outpatient appointment. Imagine a big scheme to incentivise referrals to dermatologists But without any investment in dermatologists The Brit Assoc of Dermatology would go ballistic FTs up & down the land would refuse to participate RCGP & BMA GP committee might grumble about extra work. Imagine turning up to your local pharmacists for your scrip & assuming it’s staffed by VCS & you can take what you want for free.

Making it work requires a huge cultural change across all parts of the system, and that’s a big ask. Making it work at scale from the patchwork of what is there already – across local NHS, VCS and local government cultures – will not be easy, nor cheap. We shouldn’t expect the VCS to do this for free!


Thank to James Sanderson and Emma Dickinson for helpful comments on an earlier draft. The views are mine.

This reference list for link worker related refs is also good
Public Health

Local systems and the Grand Ageing Challenge goals

This is a longish blog by Dave Buck and myself. It was done in preparation for the publication of the All Parliamentary Group on Longevity report. An edited version will eventually make it into the report. We try to set out a rationale for a wide ranging approach to longevity and improving healthy life expectancy, why both national and local approaches are important and the core ingredients of success.

As ever, they are OUR views.



The Grand Ageing Challenge will only be met if local areas move to coherent population health systems which maximise the contribution of the four pillars of population health.


National government has a significant role, the activities of each government department are crucial in shaping the environment in which communities can thrive and achieve the best possible health. Central government can (and does) set the rules and background infrastructure by which we make progress.  It also sets the context against which norms and culture is set locally.


But we know from long experience and lots of evidence that there is a hugely important role for local systems to both deliver services and set wider policies and ‘place-shaping’ that will improve health, in short local systems must become local population health systems.

Local population health systems


What we mean by a local population health system

pop health

Source: Buck et al (2018).


A local population health system is how: local areas arrange and resource activity in the four pillars of population health (the wider determinants, our health behaviours, an integrated health and care system and the contribution of our communities); and how those areas identify, recognise, lead and support activity where these pillars intersect.


Doing this, and therefore achieving the goals of the Grand Ageing Challenge will depend on: strong local system leadership; meaningful involvement of the public; ensuring health inequality reduction is a core system goal; getting the underpinning enablers right; and enabling central government policy.

Local system leadership behaviours


Achieving the Grand Ageing Challenge requires leadership of a complex population health system, this in turn requires five key leadership behaviours (Senge et al. 2015) (Naylor and Buck 2018) from system leaders:


  1. ‘Seeing the larger system’ that influences population health locally – across to the other pillars of population health and the sectors that contribute to them
  2. Recognising that not all the solutions are to be found within their organisation, sector or ‘pillar’, actively supporting those who have solutions beyond their own source of power and responsibility
  3. A shift of focus from reactive problem solving to co-creating the system and designing strategies to get there.
  4. Strong local political buy-in and support. The soft power of local political leadership (e.g. through city mayors) can cut across this complexity of local governance arrangement and appeal directly to communities
  5. Dedicated resource that can co-ordinate and help guide system-wide action. Experience suggests this need not be a large function, but it is critical to success.

Where leadership sits or rests is less important than the behaviours above.  In some places this may be the Health and Wellbeing Board, in others NHS structure such as Integrated Care Systems, or as in many places a combination, this will depend on local contexts.

The public seen as partners in health by an enabling state


Investing in communities for health needs to be a critical part of any approach to population health and meeting the Grand Ageing Challenge goals.


There has been a welcome and growing recognition of the role and power of communities in health, as well as that of individuals (South 2015; Lent and Studdart 2019; Naylor and Wellings 2019; Buck and Wenzel 2018). The communities we are born, live, work and socialise in have a significant influence on how healthy we are.  Strong communities are therefore good for health and local areas – often led by local government – are working in many ways to develop and support this (for example see case studies here


The ‘Wigan Deal’ (see box) is one of the best known and documented approaches to working with the public and communities for health, but is not alone. The Deal has given public servants and others in Wigan a set of guiding principles that inform how they work with each other and with people using services and in the community more broadly.


The Wigan Deal


Since 2011, Wigan Council has embarked on a major process of change involving moving towards asset-based working at scale, empowering communities through a ‘citizen-led’ approach to public health and creating a culture which permits staff to redesign how they work in response to the needs of individuals and communities. At the heart of this is an attempt to strike a new relationship between public services and local people that has become known as the ‘Wigan Deal’ between citizens and the council. In return for keeping council tax low, the council has asked citizen’s to work alongside it.  Wigan’s approach has been based on four main components.


Asset-based working: There has been a major drive to work with local people in a different way that seeks to recognise and nurture the strengths of individuals, families and communities and to build independence and self-reliance.  While asset-based working has been explored in many parts of England, Wigan is notable for the scale at which this approach has been adopted and for the consistency of implementation.


Permission to innovate: Leaders in Wigan Council have created a culture in which innovation is encouraged and frontline staff are permitted to take decisions for themselves and rethink how they work, based on their conversations with people using services. This has meant taking a different approach to risk – positive risk-taking is encouraged if the potential benefits for clients outweigh potential harms. It has also involved moving away from a ‘blame culture’ towards one which emphasises learning from what has not worked.


Investing in communities: Wigan Council has taken a three-fold approach. First, investing directly in local voluntary sector organisations and community groups through a dedicated community investment fund. Second, the council commissions collaboratively where voluntary and community sector organisations are seen as partners and are actively supported to develop and improve.  Finally, it has invested in citizen leadership roles at scale through roles such as community health champions (including young champions and alcohol champions), dementia friends and autism friends.


Place-based neighbourhood working: As elsewhere, organisations are attempting to work together in a more integrated way.  A distinctive feature of Wigan’s approach to this is the breadth of organisations involved – in addition to health and social care teams, multi-agency working within the borough’s seven ‘service delivery footprints’ involves the police, housing, employment and welfare services and others. This creates opportunities to tackle the broader determinants of health and wellbeing in a more coordinated and flexible way.


Source: (Naylor and Wellings 2019)



Wigan does not offer a simple, ready-made solution that other areas can adopt overnight. However, it does provide a powerful example of what can be achieved when public services see communities as assets and commit to working in a different way that builds on people’s strengths.


Significantly, Wigan’s headline achievement in relation to healthy life expectancy (HLW) is impressive. The rate of improvement between 2009–11 to 2015–17 was faster in Wigan than in most of its 15 nearest ‘statistical neighbours’ (councils with a similar population and geography), with only three of these seeing similarly positive results

(Public Health England 2019), at a time when HLE across England was largely stagnant over the same period, narrowing the gap between Wigan and the national average.

Inequality reduction as a core goal


The Grand Ageing Strategy will not be achieved without tackling health inequalities as a core goal regionally and locally.


For example, at a regional level, the London Mayor is unique currently in having a statutory responsibility to have a health inequalities strategy for London. The current strategy (Mayor of London 2018) has a twin-track focus on: those things the mayor controls directly (e.g. spatial planning, transport, economic development, housing, environment and culture); and actions of wider partners (e.g. the NHS through London’s Sustainability and Transformation Partnerships).  The strategy is supported by a number of key indicators that are monitored over time.  More major cities and regional areas need to adopt their own health inequalities strategies.


Good examples at local level include Sheffield and Coventry. In Sheffield the Health and Wellbeing Board has set itself the role of being the coordinator of the city’s approach and work on health inequalities (Sheffield City Council 2019); in Coventry, the new health and wellbeing strategy is the city’s high-level plan for reducing health inequalities and improving health and wellbeing for Coventry residents (Coventry City Council 2019).  The local NHS also needs to take inequality reduction more seriously than it does (Buck 2018), the 2012 Health and Social Care Act introduced legislation on health inequalities which needs to be more actively used (Moore 2019).

Six underpinning areas for regional and local reforms


Greater Manchester (GM) is on a journey towards a population health system covering 2.8 million people (Greater Manchester Health and Social Care Partnership n.d.), adapting The King’s Fund framework above to its own context. GM has set itself the task of reform in six core areas to help it achieve this as below; local areas should set themselves the following six goals.


Adopt a future generations and wellbeing policy


Local area need to develop an approach to future generations policy, with wellbeing at the heart, this helps local systems focus on the long-term health of their populations, not simply meeting short-term healthcare demands. GM is exploring how a regional approach could learn from the Welsh experience with The Future Generations Act (see and New Zealand’s approach to budgeting for ‘wellbeing’ (Charlton 2019).


Have an investment strategy for prevention


All ‘the headwinds’ are to support acute treatment systems in semi-perpetual crisis due to tight budgets, this creates no headroom for non-immediate spending. GM is exploring the case for a prevention investment strategy with a focus on: payment and reward systems (e.g. risk-adjusted capitation); a prevention fund; and the feasibility of setting a prevention target as a proportion of overall spend (as has been suggested by PHE and CIPFA (CIPFA and PHE 2019)).


Use existing local powers optimally


Local areas need to use existing legal powers optimally. These lie in and outside the health care system.  Regional and local areas need to be honest and ask themselves whether they are using the full powers available in the following areas: those that apply specifically to the NHS, including in relation to integrated care (NHS England n.d.); powers over procurement through the Social Value Act (Fenton 2016)); the permissive powers under the Localism Act (Department for Communities and Local Government 2011) that provides a general power of competence for local authorities over improving local wellbeing; and finally the wide range of powers in other sectors (including transport, planning and education) in ways that are likely to improve the health the population and narrow inequalities in health.


Integrate governance, assurance and accountability


There are no easy solutions to accountability, given the complex nature of what drives population health – and as a key part of that health inequalities – but it is important to be as clear as possible about where governance and assurance lies locally, and what accountability means.


In Sheffield, the Health and Wellbeing Board fulfils this role around health inequalities challenging local partners to act and holding them to account for commitments made (Sheffield City Council 2019); in Coventry, the Health and Wellbeing Board has been explicit about where the responsibilities for the strategy lie across the four pillars of population health (see Figure) (Coventry City Council 2019).


Broaden population health leadership and use public health expertise optimally


Directors of Public Health play a critical role, but they cannot be the only leaders in place for population health. The role of specialist public health expertise is critical to local systems, as our work on international cities that do well on population health has shown  (Naylor and Buck 2018); there are fewer than 150 Directors of Public Health in England, each local system will therefore need to make the best use of this scarce resource in the way to maximise its impact for population health.


But there are many more people with who can contribute, from those with the broadest roles to those with the most specialised. What works it what place and context will be different (for example, see Wigan’s reimagining of the contribution and roles of council employees (Naylor and Wellings 2019) and what firefighters are now doing in many places around England (Taylor 2017)) but every local place should have a local vision for the use of population health skills and roles in their workforce.


Fix perverse incentives


There is a difficult incentive problem in acting on population health and health inequalities. The sectors that by investing resources are likely to have the biggest impact are often not able to capture the financial rewards from doing so.  In the United States, some healthcare systems have directly invested in building and improving housing in the poorest areas (Pham and Green 2018) since they know this is important for health and because it will pay off in lower demand for their patients for whom they are only reimbursed a set sum for care.


In England there is less incentive to do the same, since the NHS does not benefit financially from improving health and lowering demand for its services; local government also has less incentive to invest since any gains in terms of reduced demand will pay off to the NHS, and not local government directly. Budgets are jointly held and decisions made more jointly between the NHS and local government in some places which helps mitigate these incentive problems; in some places the NHS is also acting more like an ‘anchor institution’ (Reed et al. 2019) and ‘looking beyond its own pillar’ and supporting other sectors for health.  But both are less common than they need to be; and these are workarounds, in the longer term the fundamental incentive and leadership problems needs fixing.

Central government asks


Central government needs to make it much easier for local leaders, organisations and systems to ‘do’ all of the above. Central government needs to commit to a national health inequalities strategy, ensure the right resources are in the right place, and develop clearer accountability between the centre and localities (The King’s Fund 2019).


A national health inequalities strategy


The effort of local leaders, organisations and systems need to be supported by a cross-government health inequalities strategy. The last strategy (active until 2010) was successful in narrowing gaps in inequalities in life expectancy between deprived and less deprived areas (Barr et al. 2017).  A new strategy needs to learn from this success, and develop further.  The King’s Fund has set out options for possible national ‘binding ambitions’ on both population health and inequality reduction and the reasons why in its Vision for Population Health ((Buck et al. 2018).


The right resources, in the right sectors


We know that public health spending is good value for money, spending on the services supported through the public health grant is three to four times as cost-effective in terms of health gain as putting the same money into the NHS baseline (Martin et al. 2019) but central government has cut the grant. The King’s Fund and Health Foundation have argued that at least £1bn extra p.a. is needed to be put back into the public health grant (The King’s Fund and The Health Foundation 2019) but a more fundamental assessment is required of the optimal budget for local government public health.

Beyond the public health grant, overall local government real spending per head has dropped by 20% between 2009-10 to 2018-19, and more deprived areas have faced larger cuts than least deprived areas, local government has been good at protecting social care services but at the expense of others which contribute to health (Harris and Phillips 2019). Central government needs to put critical resources back into local government, and to reform the way it does so, so that more deprived areas and services that support population health and will contribute to meeting the Grand Ageing Challenge do not lose out.


The relationship between the centre and regional and local systems

There is a constant conundrum about ‘what happens if what we want to happen doesn’t look like it will’ at the heart of national strategies which depend, in huge part, on the actions of local systems. The Grand Ageing Challenge will need to address two challenges.  First, that different sectors – especially local government and the NHS – have very difficult accountability (and funding) relationships with the centre; and second (and subsidiary to this) that it is not clear that existing relationships currently is optimal for the Grand Ageing Challenge.  We can – and should – learn from the strengths and weaknesses of previous regimes including those governing the previous national health inequalities and other strategies, governed through the Public Service Agreements process across government (Gay 2005).




Barr B, Higgerson J, Whitehead M (2017). Investigating the impact of the English health inequalities strategy: time trend analysis. BMJ, vol 358,pp j3310.

Buck D (2018). Health inequalities: the NHS plan needs to take more responsibility. The King’s Fund.  Available at:

Buck D, Baylis A, Dougall D, Robertson R (2018). A vision for population health : towards a healthier future. London: The King’s Fund.  Available at:

Buck D, Wenzel L (2018). Communities and health. Long read ; 14 February 2018. London: The King’s Fund.  Available at:

Charlton E (2019). New Zealand has unveiled its first ‘well-being’ budget Available at: (accessed on 18 November 2019).

CIPFA, PHE (2019). Evaluating preventative investments in public health: England | CIPFA Available at: (accessed on 18 November 2019).

Coventry City Council (2019). New four-year Health and Wellbeing Strategy published Available at: (accessed on 18 November 2019).

Department for Communities and Local Government (2011). A Plain English Guide to the Localism Bill.  Available at: pdf.

Fenton K (2016). The Social Value Act: helping commissioners improve local health and reduce inequalities – Public health matters Available at: (accessed on 18 November 2019).

Gay O (2005). Public Service Agreements.  Available at: (accessed on 18 November 2019).

Greater Manchester Health and Social Care Partnership (n.d.). Transforming the health of our population in Greater Manchester: Progress and Next Steps.  Available at: › 2019/07 › GMHSCP_-PopHealth_Progress-NextSteps.

Harris T, Phillips D (2019). English local government funding: trends and challenges in 2019 and beyond Available at: (accessed on 18 November 2019).

Lent A, Studdart J (2019). The Community Paradigm: Why public services need radical change and how it can be achieved Available at: (accessed on 16 December 2019).

Martin S, Lomas J R S, Claxton K (2019). Is an ounce of prevention worth a pound of cure? Estimates of the impact of English public health grant on mortality and morbidity Available at: (accessed on 29 July 2019).

Mayor of London (2018). Health Inequalities Strategy Available at: (accessed on 16 October 2018).

Moore A (2019). Stroke review failed to account for health inequalities, court told Available at: (accessed on 12 December 2019).

Naylor C, Buck D (2018). The role of cities in improving population health : international insights. London: The King’s Fund.  Available at:

Naylor C, Wellings D (2019). A citizen-led approach to health and care: lessons from the Wigan Deal. London: The King’s Fund.

NHS England (n.d.). NHS England » Equality and health inequalities legal duties Available at: (accessed on 18 November 2019).

Pham B H, Green J (2018). Health Anchor Institutions Investing in Community Land and Housing Available at: (accessed on 18 November 2019).

Reed S, Göpfert A, Allwood D, Warburton W (2019). Building healthier communities: the role of the NHS as an anchor institution Available at: (accessed on 18 November 2019).

Senge P, Hamilton H, Karia J (2015). The Dawn of System Leadership Available at: (accessed on 16 October 2018).

Sheffield City Council (2019). Sheffield Joint Health and Wellbeing Board Available at: (accessed on 18 November 2019).

South J (2015). Health and wellbeing: a guide to community-centred approaches Available at: (accessed on 22 April 2016).

Taylor G (2017). Guest blog: Firefighters and health – revolution or evolution? Available at: (accessed on 18 November 2019).

The King’s Fund (2019). Advancing our health: prevention in the 2020s consultation Available at: (accessed on 18 November 2019).

The King’s Fund, The Health Foundation (2019). Health charities make urgent call for £1 billion a year to reverse cuts to public health funding Available at: (accessed on 29 July 2019).


complex systems Health In All Policies Prevention Public Health

Move More – a whole system approach to physical activity



Short blog setting out the structure and rationale behind our approach to physical activity.

Thanks to Anna Lowe for helpful comments



We set out to be the most active City by 2020. The mission and vision are clear, as are the main building blocks are clear. These are set out in our the strategy is here. All of the material is on our website. (It is worth noting that the website is a good website, we have invested in this, this has (surprisingly) been problematic as people often draw a conclusion that Move More is a comms and marketing, and the annual (June) move more month)


A whole system approach Whilst the mission is clear, all the steps are not known.

The strategy is a “whole system approach” (adopted at least 3 years before the term became all new and sexy). Ive written a bit on whole systems and the like before


Our approach is whole system sort of thing – adopted 5 year before it became popular.


We talk complex adaptive systems. All three words matter – complex, adaptive, system.

Vision and mission inspired.  Infiltrate heart, minds and systems.


There is no command and control. No single detailed plan, no single controller, or no single person knows all of the things that are going on to achieve the broad goal.

Command and control is (probably) impossible. If you must adopt command and control mindset, seek to command and shift the most important leverage points in your system (see below). See Donella Meadows and similar, also Team of Teams on this


The role of controller to continually nudge the system to refocus it’s efforts to improve the trajectory of the critical metrics.


The aim of the strategy is to 1) set mission and vision, 2) orchestrate the response across many actors, NOT to describe every step in detail. The leadership role should focus on setting the rules and conditions not specifying a plan. The lead role is that of orchestrator, but doesn’t know how to play all of the instruments (maybe even what all those instruments are)


We know we compete with other strategies  for bandwidth – so we bolt move more into other strategies and other bandwidth – economy, community, NHS. Use Move More as convening force around health, skills, employment, crime and many other social issues


Though we may have a basic set of principles setting our view of the way the system operates, We wont always hold true to those principles


Serendipity has been  important. But creating the right condition for serendipity to be more likely is arguably MORE important.

Trusting in communities is key.



Is though the National Centre for Sport and Exercise Medicine, this was established on the back of the Olympic legacy. The NCSEM Board is part of the city intrastructure.

Aim is – Translation, education, influence, evaluation.

There was capital investment from Olympic legacy where we built 3 new centres – not insignificant feat. The mission is REALLY about complex system co-ordination and mission.


We DO have some structure around the main workstreams of the strategy – Communities, NHS (ex/med), Workplaces, Environments, Schools, CYP/Families, Exec Group/Co-ordinating Group, YSF provide significant backbone of this



There is a legit call for “activity”. People need to be able to see and count it etc etc…. activity is important.

Investment IS needed. Good things don’t happen out of thin air.

Of course there IS delivery of activity, across many different areas of service delivery, policy, or across many different institutions.

There are silos. This is arguably impossible to avoid

Main chunks are exercise as medicine / they don’t call it miracle cure for no reason, transport, environment, communities, workplaces.

In all of these spaces a lot going on.  You might not see it all.  We can always do better.  But it is there.

No one person knows it all. Don’t have a central team but range of people who share an aim.

That said many amazing things happen in the name of “move more” day in day out. I certainly have no idea what they all are.

Leverage points v delivery. We focus on micro stuff of delivery. This is important, but we ignore big system shifts at our peril. And this we shouldn’t be surprised when we don’t get big shift in the metrics we want to shift. For our system, what IS our story about how to shift the most important system levers. We try to focus and come back time and again to Donella Meadows on system leverage points and this 18 ways to change a system. Looking at the system, what ARE the most impactful and important leverage points and how to influence them.


Measurement, indicators and metrics

We set out to be the most active city in the country. We are well above mid table according to the Active Lives survey.

Overall monitoring is through the Move More Index here and the link to the metadata is here.

Indidividual initiatives are evaluated in a proportionate way.

We probably need to do some more on metrics that pertain to how the context or environment is changing to support the overall aim your are seeking to shift. Arguably as, or more, important than metrics that pertain to micro level interventions, or individual behaviours. So KM of segregated bike lane per 1000km of road vs % of people who regularly cycle. We also think we need to stop thinking about measuring interventions and services in isolation but overall measures that think people, lives and systems. We are doing some thinking on this – upstream measures of obesogenic environment

Often attribution is high on impossible. Yes, of course measure the impact of individual activities within the system. We may never be able to attribute activity x to outcomes y. A number of reasons – 1) The messy background, 2) Baseline trends and counterfactuals, 3) Other factors in the system beyond your sight or control

Move More Index


Where next – the future

Sheffield  have right strategy. Don’t loose nerve – locally or nationally.

We won’t be changing our core strategy but we will adapt and refresh it this year.  We will set a target “ More than now”

We will reflect on what we have learned. The acid test is wow well have we done in East Sheffield, or in those with a disability. Have to land this in an audience less receptive to the message.  Arguably the key challenge.

Coordination and connection alone is a really big job.

We would like to move towards having a more structured approach to implementing the MM plan. But doing so without killing the creative/collaborative/iterative approach that we currently have but we would like a bit more substance (so that it’s clearer to people what we actually do).

For this there will likely be a light touch implementation plans for each of the subgroups and regular coordination group meetings so that the core MM team are all aware what everyone else is doing

-so much opportunity to grow this agenda and the NCSEM agenda, feels a bit tough being stretched across both

We know we have some more work to do on upstream and infrastructure indicators. 

we havent formally mapped “the system” – all of the constituent parts, how they interact, who are the key actors and their role, whether they share the broad vision.

We will explore new hooks – carbon will likely drive the transport agenda, what implication does this have for active travel thus move more. .

Evaluationcomplex system evaluation is key. We should think in those ways

Get Harry Rutter to do complex system stuff for legislators and senior civil service??

We will be rethinking why it matters in different languages. 1) NHS and Social Care demand (Sitting is the new smoking – direct comparisons impossible – but similar order of magnitude. 5% deaths/ 7% illness). 2) Economy (sport economy directly and indirectly, skills and workforce development from sport and leisure, healthy people = productive economy), 3) social justice (use of sport around crime and criminal justice) – see this link how sport is being used as a long term drug prevention strategy, of course there will be caveats but it is very powerfully put)

We may relook at our expectation on national govt. There is SOME coverage of PA in some of the big national strategy documents. NHS – LTP is a given, but given what we know about exercise and frailty, I look forward to the investment. I am far interested in the coverage of ownership of PA in non NHS  documents.  DfT, DfE, Home Office, HMT.





Health In All Policies Public Health

Motherload – creating a cycling culture


I was invited by @heasonevents to see Motherload in November. This was part of the monthly cycle to the cinema event series –


Motherload itself is a fabulous story – both inspiring and uplifting of how one mum (and lots of others) are changing the way they think about transport for them and their families. Its long, but if u have a spare 90 mins you could do worse. There is a lot in there on culture and a lot on engineering.

I did think the film DOES need to be seen by an audience beyond that who were there  (ie committed cyclists…. but always easier said than done!)

There was a short Q&A after the event – thanks to @RichardShawld, @cyclesheffield, @douglasjsheff, @cwa_sheffield

the ideas that came up were interesting and useful. Well I thought so at any rate!

for completeness  – those ideas were:

  1.     Our fleet to invest in cargo bikes not cars. E bikes if needed (I heard there are some hills, let’s not that be an excuse!)


  1. Parking wardens on e bikes. Other staff on e bikes. See the world from cyclist perspective


  1. Address the largely cultural stuff re doing short trips on bikes or walking.

30% of all trips in South Yorkshire are less than 500m. A third!

Its not about needing to force a change in culture or behaviour – I think the culture (of just getting in the car) arises because we’ve built an environment where it’s much easier and more pleasant to get in the car – we now need to make it much easier and more pleasant to just walk down the road (or hop on your bike). This  is where the healthy streets and neighbourhoods stuff comes in – ie community, as well as commuter. Will have a bigger impact on inequalities in the city too


  1. Infrastructure, and the right standards for this.

Unsurprisingly most of the conversation focused on infrastructure.

We KNOW the supply led demand hypothesis is in play with regard to roads / cars. Some seem to doubt the same is in play for cycle infrastructure/ bikes.

All of the evidence says it is key. See this story from Paris – cycling up 50%

Building high quality infrastructure into all developments. Not just cycling, also include walking. On this, make sure you contribute to the SCR map….. leading to specific scheme design as part of a funding proposal

On infrastructure there is no doubt there is alot more every city can do, however on this it is worth noting recent changes in local govt funding. The critical picture is here.


So whilst investment is needed, funding for local government to make such investments is “somewhat difficult”. Furthermore funding broadly for active travel has a very low starting point

We very much underinvest in  active travel compared to other modes and our ROI methods completely work against infrastructure and revenue investment in active travel. To the benefit of cars and stuff

Transport planners get consistent grief …. (I think it is worth being more proactive about the other side of story, constraints they work in etc). There is also a need to shift away from considering “commuting” (economy related?) as having principal weight to all forms of journey as having equal weight. Commuters (to work) are no more or less important than any other form of traveller.

  1. Enforcement.

This is tricky space for lots of reasons, in terms of the limitations of the law and our ability to enforce it


  1. Bike to Work scheme – kit to start up. Some said


  1. Manufacturing cargo bikes and making a market led answer 


  1. More events, mass participation events. Community led and organised, SCC facilitated


9  calling out and reporting sexist based abuse of female cyclists.

I heard it was an issue. That did surprise me

Report it to the police.

It’s simply not acceptable.


  1. Bikes on busses and trams.

Many making helpful suggestions around more emphasis on bikes on busses and trams. I’d be sure “health and safety” is used as reason for why we cant, it may be also about space


There was a healthy discussion on whether we wait till it is all aligned and perfect plan before we really push on it … or just get on with pushing toward the tipping point in lots of different forms and styles

the links

link to the film:

Cycle Without Age.

Recycle Bikes Cargo Bike Hire:


Public Health

Why hasn’t what is being observed in the USA on opioid addiction been seen here. Could it?

Asked q on twitter yesterday in prep for a research interview I am doing next week for a researcher from Princeton

Very helpful set of responses

Put here in full. Not especially sorted or ordered. Use as you  need to
Why hasn’t what is being observed in the USA on opioid addiction been seen here. Could it?

1. Continuity of record, via GP
2. Expectation* of prescribers, patients & pharmacists that repeat scripts – even privately initiated- default to NHS
3. Patients not seen* as customers
4. Seeing your own* expert generalist (aka GP) regularly (*we’ll soon lose these)
5. no DTCA in UK
6. We’ve not been subjected to intense industry-led ‘pain = fifth vital sign’ campaign. This thread is quite insightful. Look at the graph…..
7. I suspect the lack of a direct financial incentive for prescribing more expensive therapies has played a role.
8. from my viewpoint, as a hospital prescriber of opiates, we use modified release less often than the states, and rarely send patients home with strong opiates. Was shocked to hear US colleague go home with 4 weeks oxycotin post casearean, we usually give none!
9. The big issue with modified release is that they are the 3rd largest risk factor for persistent post operative opioid use. The Australians have banned them for post surgical pain, and the US ‘s FDA have essentially done so too. We should too.
10. I would say Private health care system plays a part. In the UK there isn’t a necessity to satisfy the customer as they do in the US. I also think re-addiction could be a factor as ex addicts are easily prescribed opioids in the US but it’s avoided in the UK.
11. You can buy eg Cocodamol Over The Counter (OTC) albeit dose of codeine is lower than prescription-strength, but there’s a warning on packet exterior not to use for more than (three days?) & seek medical assistance if pain persists, so people will go to see GP/ER as it’s £free.
12. in UK, most people are more likely to take opioids short-term, go to doctor & get underlying cause treated, whereas in US there’s temptation/necessity to defer $$$ treatment & get by with $ pain meds, so they take them longer and are more likely to get addicted?
13. The harm is not equally distributed. It is happening in areas of deprivation where (risky) dependency forming medications are prescribed more frequently and/or for longer (see PHE and lots of evidence prior). Whilst opioid dosages are being reduced in some areas…….we still risk creating another great health inequality iatrogenically. At same time unilateral deprescribing risks the therapeutic relationship and risks pushing patients to street meds of dubious quantity. ….Therefore best not to start prescribing. See RCGP’s Secure Environments Group’s Safer Prescribing in Prisons for traffic light risk assessment as valid outside prisons as in…
14. I’d only add how difficult it can be to get a prescription in England…..for almost anything. Particularly in primary care. Which is much stronger in UK than US. Hard to imagine pill factories in UK. But may be some unmet need..
15. E.g. of packaging here in UK: “* Can cause addiction * For three days use only”…
16. I suppose in UK, most people are more likely to take opioids short-term, go to doctor & get underlying cause treated, whereas in US there’s temptation/necessity to defer $$$ treatment & get by with $ pain meds, so they take them longer and are more likely to get addicted?
17. You can buy eg Cocodamol Over The Counter (OTC) albeit dose of codeine is lower than prescription-strength, but there’s a warning on packet exterior not to use for more than (three days?) & seek medical assistance if pain persists, so people will go to see GP/ER as it’s £free.
18. Mix of: Fentanyl, different access/financial relationship pharma-doctors, history of easy access to opioid prescriptions shapes patient expectations. Easier licit access = more available for diversion. If you need more,
19. If you supply addicts with monitored Pharma grade methadone and Pharma grade opioids and keep them steadily supplied, you’ll be fine. If they can’t access then the illegal market will supply, with cheap and deadly Fentanyl you’ll have more dead bodies than us
20. The biggest difference is that we think we have an opioid epidemic but we don’t—we have a Fentanyl poisoning epidemic. Cartenafil etc are many times stronger, and being brought in illegally. When doctors cut patients off legal pharmaceuticals here, patients get illegal ones
21. And then patients die because the illegal ones are 20 times stronger. Post-surgery new patients can be safely prescribed and tapered down. Addicts will never stop, so we need the safest harm reduction possible, which is Pharma made —because illegal injectables DO kill patients
22. In the u.k we now know about rescription opioid addiction and are doing something about it. There was a piece in the Evening standard last year about the prescribing of Opiods and the dangers.
23. Easy access – online pharmacies. Online prescibers
24. Pain management systems
25. Labels and warnings
26. Knowledge: When Crack users were being sold “pow” and were told it was Methamphetamine they started to buy crack elsewhere. When Meth hit the US people didn’t know what they were getting into. We tend to be able to warn people of the dangers before things take off over here….
27. Availability and quality are also a factor. We see things like Krokodil in Russia which is due to not having consistent supply of quality heroin. In the US supply varies, opioids are available and consistent so are far better option for an addict.
28. From what I’ve seen in Canada which has the same problem, and it shocked me when I arrived, GP training and access to psychological support are the main differences I see. GP training in the UK has a significant focus on psychosocial aspects of illness and the hidden agenda, 1/ From Michael Balint’s work. So UK GPs are more ready to recognize that the presentation of illness may have a deeper or comorbid psychological component. In Canada I find there is a strong focus on Emergency Room Medicine by GPs many of whom work also in ER and bring the same 2/ Approaches focusing often on the superficial presentation of illness and the obvious complaints. Even if the psychological aspects are recognized there is little to no resource for high quality counselling and what does exist is psychology for which there are long waits. 3/ Unlike the UK GPs don’t employ counsellors as the billing system wouldn’t remunerate them. The billing system drives a lot of clinical activity directly/indirectly e.g. many patients with a diagnosis of asthma / COPD who haven’t had spirometry bc GPs don’t have spirometers 4/
29. its here but not reported. Youngish people becoming older, distressed by pain on cocktails of opiates, gabapentoids, SSRI and TCA antidepressants and need something more now. Usually been to secondary care services and counselling not helped. Using cannabis and now cannaboid oils at home. Although worse now wont reduce prescribing. How many deaths have their repeat prescription charts examined for unsuspected causes like QT issues? We do not scrutinise for causes of death enough as noone wants postmortems and inquests.
30. IMO You understand this is partly a result if a generation of GP education moving from paternaliatic to shared decision making at the expense of knowledge and letting patients make decisions interplaying with Incompetent national guidance and management from pain clinics?

21.  And there are still too many people on long term opioids where other pain management strategies would be safer and more effective. The reason it’s escalated less than US is they’re not on oxycontin)

Thanks to
@nicholasalevy @JIDMMatheson @doctorsdilemma @AmyMcNTweets @jpraft @DrAnneMurphy @SimonGilbody @Louise243 @EllieHoul @DrCJohn @MccabeCJM @pmw777 @Louise243 @RandomDaveR @pmeiersheffield @janewilcock @RCGPSecureEnvi1  @cleverestcookie


Opioids – The Opioid Timebomb: Are they doing us more harm than good? A special Evening Standard investigation

Nick Hopkinson review of American overdose

Nick Hopkinson: American overdose

LSE article Why has the US opioid crisis not spread to the UK? Thank the NHS

Curtis et al – was the key open prescribing data analysis. Note the OME trends


this in perioperative use of short term opioids is good


this is good from Cathy Stannard –


Tracing the US opioid crisis to its roots – understanding how the opioid epidemic arose in the United States could help predict how it might spread to other countries’ –


Fifth vital sign

Public Health

What do you actually *do* then

What do you actually do then


The question every DPH detests. This is a niche blog (!) to give my answer to a question I get asked a lot.


My answer depends on how much detail folk want. Graham Mackenzie did an excellent primer on what is “in” public health, I often send this to people. What is public health? Some reflections for teaching – #ScotPublicHealth, the slides are also good


In terms of skill sets needed the Faculty of Public Health curriculum is it good as any


1   The short answer

My stock answer is thus – In short, go to meetings. A lot of them, that is basically the currency of the business.


Precisely what meetings this encompasses cover the span of public health practice – from air quality, economic policy, environmental health and housing through tobacco control and obesity to violence reduction and health care strategy. And everything in between. The meetings can range from big set piece partnership meetings such as a Health and Well Being Board, a Community Safety Partnership or the Safeguarding Board through to management team meetings through to 1:1 with a very wide range of people.


2   In more detail – What is a DPH supposed to do

The Association of Directors of Public Health have eloquently described what they think a DPH (and by extension their team) ought to do, link here.


For most us, the role exists in five broad chunks

  1. The “social determinants” of health. There are many of these, many different systems, actors and constituencies. They all interact. You need to understand and influence how those systems work to create better health
  2. Lifestyles. Most of us are reframing this in two ways both in a behavioural psychological context (most pertinent to individuals) and commercial determinants (most pertinent to the real drivers). This require some nuanced thinking
  3. Health protection – screening, vaccination, response to incidents
  4. The PH grant and how this is used. There are a set of set of mandated services inherent within this.
  5. Public Health Intelligence. A combination of applied epidemiology and data science. This obviously encompasses things like “needs assessment”, but also evaluation and analytics to answer bespoke questions


I did an interview once for Rachel Steen for the Fair Health blog. And three shorter pocasts for Prof Shickle, here, here and here. I once did a long lecture setting out an approach, it is this blog, the lecture with some linked slides. Save for a rainy day!


All up this becomes about system leadership (whatever that means) and orchestrating many different things. The big idea is that there isn’t a single big idea.


Advocacy for national change remains important, see this RSPH list of 20 achievements of 21st century (so far). None of these things would have happened without a serious advocacy effort, as illuistrated here with the smoking in public places ban.


This is obviously well beyond the expectations of “the grant” per se. Whilst there are a set of statutory requirements of a DPH (see above) many operate in a far wider space. The DPH role is supposed to be about creating and implementing a strategy for improving health and closing the gap between best and worst. Think through that in the context of what determines health and act in a way mindful of this .





3   The full skinny


There’s a lot of legislative expectation


The LA PH Function Act is quite dry, as is the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 . The role of a DPH was also covered in The NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012, this includes in Part 3 the role of the DPH, and a related statutory instrument that covers Dental role

Well, you did ask……


In simpler language, there are within the Act as set of  prescribed functions set out in appendix c of the Grant Condition letter, with further detail in the DHSC policy papers on PH in Local Govt. the Statutory Functions include sexual health, NHS Health Checks, ensuring arrangements for health protection, advice to NHS commissioners, the National Childhood Measurement Programme, prescribed 0-5 services. Of course there are a wide range of services that are funded by the PH grant that are not mandated or legislated for.


………………..Try explaining that in a pub, after a drink or two!


4     Im still interested, what should I read

Reading list

I often send folk a set of reading. It sort of depends who is asking and in what context:

This reading list from Tim Ewell Sutton is excellent and gives a great grounding in most of the basics. The additions from others at the bottom of the thread are also excellent. Ben Jane later tidied it up a little bit and there are a number of other helpful references on his site.

Health Foundation health strategy, Specifically the resources guide

Michael Marmot’s The Health Gap, The Challenge of an Unequal World

Norman Sartorius’ paper The Meanings of Health and its Promotion

The Lancet editorial What is health? The ability to adapt:

Geoffrey Rose’s 1985 paper Sick Individuals and Sick Populations

Health Affairs’ Health Policy Brief: The Relative Contribution of Multiple Determinants of Health Outcomes

The WHO’s 2008 Final Report of the WHO Commission on the Social Determinants of Health:

Michael Marmot’s 2010 Fair Society Healthy Lives: The Marmot Review:

The Department of Health and Social Security’s 1980 Black Report – Inequalities in Health

Perspective of a jobbing DPH Public health ethics, through the eyes of a front line Director of Public Health

University College London’s Institute of Health Equity:


Causal thinking and complex system approaches to epidemiology in IJE

Complex systems thinking and current impasses in health disparities research – AmJPH

Lankelly Chase’s Theory of Change – a theory of change that identifies changes at the systemic, structural and cultural level to help improve the quality of life of people most exposed to social harm:

New Philanthropy Capital’s Systems change: a guide to what it is and how to do it – an exploration of the literature on systems thinking:

Public Health

Mandatory vaccination – a bad idea

Mandatory vaccination – a bad idea

This was cropping up quite a lot of late. I was persuaded to write down my thoughts. I did so on twitter, but I have put them here in one place.

There is zero doubt we need to do better in this space. Coverage has slipped, the UK has lost WHO measles free status. In Yorkshire coverage of 2 doses of MMR at age 5 is circa 90%, it should be 95. The 90% masks variability, it is much lower in some cohorts. So we DO need to address this. But mandating vaccination is not a good idea.

Mandating my erode trust in vaccination, which in the UK is reasonably high, after years of work. It wouldn’t take much to significantly erode that trust, and I would fear that mandating would be twisted by some (who have a great deal of influence) to do exactly that.


there  is plenty of evidence to support a view around mandating being a bad plan

There are plenty evidence on this. MacDonald is the best I have seen.  Mandatory infant & childhood immunization: Rationales, issues and knowledge gaps

Key points here

  • Globally, many countries have enacted, strengthened or contemplated mandatory infant and/or childhood immunization.
  • No standard approach to mandatory immunization; varies from soft/flexible to rigid/hard.
  • Varies in terms of vaccines included, age groups covered, penalties, degree of enforcement, and if AEFI compensation.
  • There are ethical, legal and public health implications.
  • Meager evidence on benefits of hard mandatory; may have unintended consequences.
  • Mandatory immunization does not guarantee improved vaccine uptake rate.

Pertinent questions include:

  • Is there a problem with uptake rates? Or is it another problem that is being addressed?
  • Is this the right solution at this time in this context?
  • What components need to be in the mandatory framework (Table 2)?
  • Do these components fit the culture, the context, and the specific problem that the mandatory program is trying to solve at this time?
  • Do other proven strategies need to be part of this change to the immunization program?
  • Will the shift to a mandatory program be accompanied by an increase in resources to the immunization program, and where will those resources come from (i.e., will other public health actions be compromised)?
  • What might be the public response to such a change, especially if choice is restricted, and can this be effectively managed?
  • Is there potential for harm to vulnerable populations? i.e. unintended consequences


see also Cantor writing in NEJM about experience in New York and other US cities, a cautionary tale.



2     what SHOULD we do then

Three broad groups

In my head there are broadly 3 groups

Group 1. The refusers. Probably a small % of the whole. I would wonder whether there is anything much we can do there apart from keep a firm steady sensible line. I fear that going toe to toe here would end in a fierce argument with antivax groups, giving oxygen and may erode trust

Group 2 the hesitant. A simple strategy of building trust with clear and consistent positive messaging. This can and should be done through multiple channels, through human interaction in clinical contexts, though mass media, social media and others.

Group 3. The group that the system misses, slips though net – the strategy here is basically sort the system failures. My sense (and I am happy to be challenged as I don’t know) is that 3 is probably the biggest group. Group 3 there are a group who are not refusing, they are being under-served.

Nationally we have good data to suggest confidence in vaccines is high, PHE do an annual survey on this which indicates this very clearly. Thus the problem we are trying to solve is largely a SYSTEM issue that we need to properly address not a vaccine hesitancy or refuser issue.

Recent national guidance on ‘how to do comms on vaccination’ highlights not giving vaccine deniers more oxygen.

I feel we should be more honest that vaccination is not 100% effective, it’s a science we’re always learning more etc so as to engage in conversation with people’s concerns in more of a humble and less of an authoritarian way. Being authoritarian will play into the arguments of the antivax constituency





3   Vaccine refusal is NOT a disease

Occasionally I have seen “vaccine refusal” being labelled as a disease. This leads me to five massive concerns –

1) disease mongering

2) ist NOT a “disease”. may stigmatize a group of people. not sensible

3) medialises what is a social or system issue

4) might lead to wrong response

5) arguably a “medical response” (term used advisedly) isn’t what needed





4     Strategies for addressing the antivax message

On strategies for combatting antivax narrative which widely circulates on social media, I remain of the view that I am reluctant to go on direct confrontation, it simply gives oxygen to something. Its worth being aware of the tactics and strategies, the recent interest in the concept of firehosing is relevant in this regard. See here applied to antivaxxers, and the RAND report for a wider description with some thought given to counter measures. This recent piece in the BMJ on old and new power was also excellent . three broad lessons which have great relevance to this issue:

Lesson 1: create context, not content New power communities offer real agency to participants create context for people to do so much more than consume depersonalised leaflet can’t compete with distributed, customised messages

Lesson 2: don’t bring a fact to a narrative fight Experts can arm themselves with white papers, peer reviewed studies, and symposia; if these are our only weapons, we will only ever get so far. Experts are increasingly distrusted, the “we know best” mindset is counterproductive. No coincidence that the most effective climate advocacy in the world right now comes from the improvisations and stories of a 16 year old girl rather than the strategic plans of a generations old institution

Lesson 3: not old power v new power; old power + new power Dont despair at, criticise, and wish away the antivaccination movement.  Learn new tactics


It’s not about fighting misinformation with “more or better evidence”, there is a clash of strategies and tactics; combined with different stakeholders ability / willingness to get the nuances in studies + different understandings of “what counts” as evidence. The strategies suggested by RAND on countermeasures are excellent.

This is nuanced stuff and needs a nuanced response from people highly skilled in such strategies




5     Final thoughts

There MAY be merits, personally I don’t buy it

But BEFORE we go to mandation we ought to make sure we have fully exhausted higher order (and more evidence based) strategies. It might also be necessary to think through enforceability and sanction (and consequences of sanction) of such strategies, would there be exceptions? What are the consequences for broader issues around informed consent and relationship between clinicians and parents.


I should be clear I am writing here as a Director of Public Health in a British context. I know these issues will have nuances across the world, that underscores the need for nuanced approaches led by local evidence and skilled individuals.




Public Health

why “health” matters to “the economy”. An economy with well being at the heart (1)

1              Lines of argument

Health / wealth = Two way relationship

Economic prosperity AND health & well being are BOTH mission critical for the city. This section sets out why

The economy is everything, everything is connected.

The economy is not just about the activities of private sector business.

Investments in both public sector, voluntary sector and the actions of individuals all contribute to outcomes we individually and collectively value and thus what we consider “the economy”. Sometimes measurement and valuation is difficult, but that doesn’t make it less important. Everything is connected.



Healthy Life expectancy as an economic issue

Nationally (and Sheffield) HLE = 60. Thus 7 yrs of less than good health whilst working age.

How healthy we are / not has critical implications on how actuaries advice govt re retirement age




There is deep inequality in the distribution of illness. It is an economic productivity issue, as well as intrinsically bad

There’s a 25y gap in healthy life expectancy (HLE). Age of onset – 45 v 70 before multiple conditions become an issue. A baby born in Darnall can expect to get to 50 in good health, a baby born in Fulwood can expect to get to 70 in good health.



the inequality in health outcomes is also intrinsically linked to inequality in economic outcomes.

Many people and organizations have commented that the way in which the economy has developed has left people behind, often exacerbated poverty. There is a strong research base on this, and this has led to the establishment of terms like “inclusive economy”, which describes an effort to ensure the economy works for everyone. Given that health inequality is essentially driven by wealth inequality this underscores the importance of our efforts around creating an inclusive economy as important for inequalities in health and well being.



Impact of illness on Sheffield Economy

Estimates that illness costs Sheffield economy £1bn (as a comparator, NHS spend = £1.1bn)

100k working days lost a year to mental illness (under estimate??). MSK similar?



some specifics – Heart attack, cancer, stroke

something most commonly associated with age

is very common in <65s than older. Many people loose significant function and don’t come back to work.



Multi morbidity

more common in working age than old. See Barnett, Lancet 2012 and plenty of local level analysis

Multi morbidity (having more than one condition) is more common than having a single illness.

There are more working age people than the elderly with multi morbidity and this is very unequally spread across our population. Thus underscores the importance of the health of the working age population. As > 50% of over 60s have 2 or more LTC this makes prevention and delaying and treating those LTC a QOL and economic issue



Put most simply, poor health, which is quantifiable, has an impact on economic growth. And investment in better health can have an impact on economic growth.

Simply, a healthier population is likely to be more economically productive (and to need less spending on healthcare and health-related benefits). This is a two way link, a more prosperous society is likely to be healthier. Just as HS2 is seen as an investment in the economy, so is investment in a healthy population.

We should consider health as a balance sheet asset, not a cost



Measures of economic progress

What we measure and value is important, this is one of the things that underpins calls to widen the measure of economic growth from solely GVA to a wider measure that includes social benefit. It would be easy, in narrative terms at least, to also include resilience and cohesion into the things we value in our economy.




Health and wel being as a central component of economic strategy

The above issues are not issues that will be (only) solved by more, or better health care services. That is necessary but not sufficient

Poor health has a direct and indirect impact on economy at individual and societal level

Thus the central “health” challenge – stalling healthy life expectancy, and inequalities of that – aren’t a “problem” for the NHS, they are a problem for the whole economy.

Keeping people well is thus a major national infrastructure project. A bit like HS2. With those kind of timeframes. How seriously are we really taking this.

This is the reason why health and well being should be a central component of economic strategy.


2              Some references to support the above


1)            My own DPH report 2018

my DPH report  set out an argument why economy and health go hand in hand and how LAs can bring wealth and health together


2)            NHSA report

The Northern Health Sciences Alliance have also recently published detailed analysis on the connection between poor health and productivity

reducing the number of working aged people with limiting long term health conditions by 10% would decrease rates of economic inactivity by 3 percentage points in the Northern Powerhouse.

30% of the gap in productivity between north and south is attributed to a HEALTH gap, not skills / education / transport other.


3)            CMO report 2018

The 2018 Chief Medical Officer for England annual report

6% of healthy men are out of work; 25% of those with a longstanding illness.

28% of the sick are in poverty and those with less education educated are far more likely to be ill and on sickness/disability benefits than those with the highest levels of education.

half of those in incapacity benefits have a mental health problem.


4)            Health Foundation blog on data on time spent in good health

People in the most deprived areas of England spend less time in good health

reproduced here nearly in full as it is so good


Analysis of 2011 Census data shows that while the proportion of people reporting good health declines with age, this decline begins at younger ages in the most deprived parts of England. By the time they reach age 55-59, only 50% of people living in the most deprived local areas report good health. In contrast, in the least deprived areas, 85% of people in this age bracket still report good health. In these areas, the share of people reporting good health doesn’t drop to 50% until age 75-79 – a whole 20 years later.






Periods of poor health may occur at any age, including working age. This occurs most often for those in the most deprived areas.

This chart not only shows how the share of the population reporting good health deteriorates as people age, but also indicates that actions to improve health should occur across the life course. Only 50% of people living in the most deprived 10% of local areas in England report good health by age 55–59. In the 10% least deprived of local areas the same proportion report poor health a whole 20 years later, at ages 75–79. This is of concern as having an unhealthier working age population may negatively affect an area’s productivity.

5)            quote from BMJ from Jo Bibby and Adam Briggs

……..If people’s health is treated as an expendable that can be sacrificed when required to promote other government interests, the treasury will find it harder to deliver on some of its own economic measures of success.


Maintaining and improving people’s health is essential to ensuring that they can participate in the labour market.


Middleton – Time to put health at the heart of all policy making. BMJ

Inequalities in health cost £65bn (€74bn; $83bn) in lost productivity and taxes and increased benefits payments plus £5.5bn for direct NHS treatment in 2010. From Marmot review


6)            Poor health is now the single biggest reason for economic inactivity

See ONS Economic inactivity by reason (seasonally adjusted data


7)            health related labour market exit

We KNOW significant numbers leaving labour market early. And that this is unequally distributed

And thus productivity gap issues (also commented on in NHSA report, and chief med officer annual report)

See this study from Holman recently on the extent to which different chronic conditions are risk factors for disability-related employment exit. It analyzed the extent to which associated symptoms and limitations, such as muscle use limitations, pain and mobility are risk factors

Key points

Increasing life expectancy has led governments to implement reforms aimed at delaying retirement.

Chronic conditions are an important barrier to this given their association with pain, functional limitations, depression and ultimately lower life expectancy.

Data from waves 1 to 8 of the English Longitudinal Study of Ageing

Alan Walker and Daniel Holman blog on this was excellent in summarizing the key points from the perspective of the HLE challenge

Each year tens of thousands of older workers in England leave employment prematurely due to poor health and disability.

What’s striking, and supported by previous research, is the significant proportion of employment exits that arthritis and depression account for.

Furthermore, large numbers of people are leaving work because they have limitations in use of their muscles, and experience pain and mobility problems.

There are significant gains to be had by focussing on chronic conditions, disability and employment exit, and the possibility to address gender inequality in the process. Although more work is needed to fully tackle the issues, there is already enough evidence to make major advances on workplace well-being and age management.

To do so would greatly advance the extending working lives policy goal as well as improving the well-being of hundreds and thousands of older workers

For every 8m people stay in work GDP increases by 1% (needs ref!)

9              Link between life expectancy and GDP

See Swift

A similar, long run, cointegrating relationship between life expectancy and both total GDP and GDP per capita was found for all the countries estimated.

A 1% increase in life expectancy resulting in an average 6% increase in total GDP in the long run, and 5% increase in GDP per capita.

This is underplayed in economic policy. It is also likely significantly underplayed in the estimation of correlation. Given what we know about healthy life expectancy, it is not unreasonably to think that the impact of HLE on GDP would be greater than LE

Total GDP and GDP per capita also have a significant influence on life expectancy for most countries. There is no evidence of changes in the relationships for any country over the periods estimated, indicating that shifts in the major causes of illness and death over time do not appear to have influenced the link between health and economic growth.


10)          population health as pathway to economic development (again, nearly in full below because it is SO good)


I’d like to take this concept another step—or leap—forward. It’s important but it’s not enough to understand the impacts on health when we’re making decisions about jobs, transit, crime, social services, housing, etc.

It’s time to also consider the impacts from health in these sectors. In other words, investments in evidence-based health interventions can be expected to yield enormous community and economic benefits, and we ought to be paying more attention to that.

For example, suppose you want to improve lifetime earnings. A typical response would be to invest directly in education or job training (and those are good things). But, what about investing in infrastructure that reduces lead poisoning? Children with high lead levels in their blood are more likely to require special education, have lower IQs and ADHD, and be involved in crime. They are less likely to be ready to start school and to graduate from high school. A 2009 Environmental Health Perspectives Journal article investigated the costs and benefits of lead hazard control for children under the age of six and found that, for every dollar spent on lead hazard control, $11-$227 were returned in benefits. The vast majority of these benefits accrued in the form of higher lifetime earnings and associated tax revenues, but the financial benefits also reduced costs in a variety of sectors, including special education, health care, and criminal justice. Now that’s community and economic development!

Once we start to treat health as a linchpin to community and economic development, we can begin to insist on different investment decisions and improve our programmatic approaches to power boost results. What could we be asserting to make this point of view more commonly understood? Here are three ideas:

  1. Health is an economic engine.

A series of 2008 symposium papers, entitled Health And Economic Development: Reframing The Pathway, argued for viewing “health as an economic engine” in which “improving economic conditions to improve health, and improving health to improve economic conditions, leads to the possibility of ‘virtuous cycles’.” They went on to conclude that as the cycles continue, there are ever-improving health and economic conditions. Interestingly, some of the authors,  David Mirvis and  Joy Clay, further posited that “a health intervention…maybe a necessary precursor or parallel to economic interventions. The success of an economic intervention may be dependent upon the health of the population, as an unhealthy workforce may be unable to support the needs of an economic industrial stimulus.”

This case for health as an economic engine seems fairly obvious when it comes to personal wealth and business profits, as demonstrated in these stats:

  • One additional chronic disease at age 16 is associated with a 5% reduction in the probability of employment at age 42.
  • Raising the average birth weight of low birth weight babies to the mean birth weight of all U.S. babies increases their lifetime earnings an estimated 26%.
  • The overall economic impact of absenteeism and presenteeism (working while sick) from common chronic diseases exceeded $1 trillion in 2003, and may reach $5.7 trillion by 2030.

Finally, it appears that health spurs economic growth through a variety of macroeconomic factors, such as increasing savings rates and foreign investment, improving social structures and community cohesion, and altering the long-term demographics of a population.  One study that looked at 13 developed countries found that a 1% increase in life expectancy resulted in an average 6% increase in total GDP in the long run, and a 5% increase in GDP per capita.  Another study concluded, “good health has a positive, sizable, and statistically significant effect on aggregate output.”

  1. Population health investments can spur jobs, earnings, and fiscal soundness.

A few months ago, I was poking around one of my favorite websites, the Washington State Institute for Public Policy. From its cost-benefit data, I constructed a portfolio[3] of various interventions related to population health. I simply chose a mix of population health interventions, from clinical to school-based to community-based. The returns from this portfolio are shown in the two graphs below (see the footnote for detail on all those acronyms):

Did I cherry pick the interventions? Of course I did! Why would one invest in the lowest return stocks in the stock market? But go to the website, and you’ll see that there are plenty of other high return investments.

  1. Key investments we currently make in economic development are underperforming.

Business tax incentives aimed directly at job creation as well as business retention and expansion–often administered through enterprise/empowerment zone type programs–are a ubiquitous instrument of economic development. In a just released paper, the  Upjohn Institute estimated that, nationally, state and local tax breaks for business incentives total $45 billion, yet “incentives do not have a large correlation with a state’s current or past unemployment or income levels, or with its future economic growth.”

The  Federal Reserve Bank of San Francisco wrote in its March 2015 Economic Letter: “Our overall view of the evidence is that state enterprise zone programs have generally not been effective at creating jobs. Moreover, even if there is job creation, it is hard to make the case that enterprise zones have furthered distributional goals of reducing poverty in the zones, and it is likely that they have generated benefits for real estate owners, who are not the intended beneficiaries.”

These general findings are echoed in study after study at the state level.

  • An  independent evaluation of New Jersey’s Urban Enterprise Zone (UEZ) program found that, from 2002 to 2008, the state invested a total of $276.6 million but received only $0.08 in state and municipal tax revenues in return and $0.83 of “ripple” effects on the economy (i.e., net negative returns). And all 37 UEZ municipalities were in the bottom 10% of distressed cities according to New Jersey’s 2007 Municipal Revitalization Index.
  • The  California auditor found, “We could not determine whether the $1.5 billion of foregone revenue related to a research and development (R&D) credit in fiscal year 2012-13 is fulfilling its purpose or benefitting the state economy.”
  • In a  review of business incentives in New York state, evaluators wrote: “In the 2013 tax year, New York State provided an estimated $1.7 billion in 50 business tax credits to encourage taxpayers to engage in specific activities. . .There is, however, no conclusive evidence from research studies conducted since the mid-1950s to show that business tax incentives have an impact on net economic gains to the states above and beyond the level that would have been attained absent the incentives.”

Why would we spend our money this way? If our personal investment portfolios had such mixed results, I don’t think we’d hesitate to pick new stocks. It’s incumbent on us to be optimizing our public investments as well.

In fairness, many states– Maine and New Jersey, for example–are beginning to evaluate and call for reform of their business tax incentive programs. As best I can tell, however, there remains no wholesale rethinking of the general approach. We have to ask ourselves: are business tax credits for job creation the best way to increase jobs and therefore the income of residents in a community?

Maybe offering business tax credits for creating health (a la Mirvis and Clay) would be a higher yield approach. For example, suppose the portfolio mix I used to generate the graphs was the right mix for New York State, and further suppose that New York spent about half of its tax credits ($800 million) on this portfolio, and that the yield was only half what the evidence projects. In this scenario, taxpayers would see a yield of more than $3.6 billion, and participants would reap another $4.5 billion of benefits, mostly in the form of higher labor earnings.

No doubt this is an overly simplistic calculation—variables such as effect size and dosage, differences in costs/taxes between New York and Washington, and potential interactions across interventions would need to be taken into account for a proper analysis. But the point is that, even if we cut returns in half from what the evidence suggests, we still have some very healthy yields—very healthy compared to current investments. And that is an ROI worth some serious