As ever, thanks to my team – who turn my random brain dump into coherent sentences – and others who help me develop ideas
I’ve just published my 2017 Annual Report.
Key messages below
- The Healthy Life Expectancy story, and why matters
- Adverse Childhood Experiences
- Mental well being
- Multi morbidity
- Oh, and inequality
Healthy Life Expectancy story, and why matters
The latest figures for life expectancy and healthy life expectancy for both men and women in Sheffield suggest that previous improvements in health and wellbeing may be stalling and, in some cases, worsening. This is a cause for concern.
We have previously noted the very small improvements in women’s life expectancy in Sheffield over the last 10 to 15 years and more recently this has ground to a halt. In the most recent period analysed however, we have seen men’s life expectancy decrease from 78.8 years in 2012-2014 to 78.7 years in 2013-2015.
This trend is not unique to Sheffield and we are beginning to see similar changes across England as well as internationally. In the USA, for example, life expectancy for both men and women is now in reverse. There are many theories to explain this stall in improvement, some of which are discussed below
A similar picture emerges when we look at how long we can expect to live in good health (healthy life expectancy). For both men and women in Sheffield, healthy life expectancy is declining, although the decline is steeper for women than it is for men. Women’s healthy life expectancy decreased from 61.5 years in 2009-11 to 59.9 years in 2013-15 and men’s healthy life expectancy decreased from 59.3 years to 59 years over the same period. Although Sheffield’s experience is broadly reflective of the national position, it continues to be significantly worse for both indicators.
Inequalities in life expectancy and healthy life expectancy also show relatively little change with the gap in life expectancy between the most and least deprived men in Sheffield narrowing from 10.1 years to 9.9 years over the period 2001-03 to 2013-15 and widening for women from 7.6 years to 8.1 years. These factors are the main drivers of the unsustainable yet largely preventable growth in demand for health and social care services.
There are many theories on why historic improvements in healthy life expectancy have stalled. There are three principal hypotheses. The first relates to the consequences of past deindustrialisation policy, the consequences of the Regan economic model of deindustrialization and trickle-down theory. This led to large numbers of marginalised and disenfranchised people, and significant job losses. Obviously this had direct consequences and long term indirect consequences and these have been most powerfully explored in the excellent work from Glasgow “History, politics and vulnerability“.
The second explanatory factor is the long term consequences of choices people make in an environment where health is not the easiest or the default option, or indeed where the environment itself is harmful (physical, social, environmental, economic). This isn’t about “lifestyle choices” individuals make, but concerns the negative ways in which the environment influences those choices. This may now be catching up with people.
Lastly, austerity and the direct and indirect consequences of this, is almost certainly a more recent factor and there is growing research evidence and expert commentary to suggest this has made the problems described above more acute. See this article by Danny Dorling for some explanatory points.
This piece (from USA but same principles apply) explains why an apparently marginal change in a metric like life expectancy is a huge deal.
Overall, this means there are more people in poorer health at a (slightly) younger age than previously. There is no doubt this is driving demand for health and social care services. This demand is not evenly spread across the city, underscoring the need to focus attention on those with most need whilst maintaining an offer for all. We will also need to look at the type and model of health service delivery, including increasing the emphasis given to primary care and care outside hospital.
What to do about it
Professor Michael Marmot and other commentators are consistent in their suggestions about why this is happening and what to do about it. The solutions are well beyond the NHS, although the NHS has an important role to play. Local analysis has identified a number of areas to target. These are not the only targets of course but they represent the most important.
More accessible or better health services will not solve this problem, important as they are. Better health services are necessary but not sufficient. The five themes of Marmot’s original work remain valid: childhood and early development; education and lifelong learning; healthy and sustainable places; minimum income for health; work; and a social determinants approach to health improvement.
The SCC public health strategy has identified a number of areas of focus.
These areas are not necessarily service or organisation specific, nor are they where (significant amounts of) Public Health Grant funding is currently committed; rather, they are concerned with establishing the right conditions for health and wellbeing to flourish in Sheffield.
These include , but are not limited to:
· Housing and health – our home is a key setting for health so good quality, affordable housing represents a community asset that impacts directly on a broad range of health and wellbeing indicators
· Work and health – as part of discussions on health and economy we need a comprehensive work and health strategy
· Healthy transport – the key measure of the city’s transport strategy will be how well it incorporates active travel and supports a modal shift in how people get about on a day to day basis
· Air quality – pollution (mainly from diesel) is responsible for around 500 deaths a year in Sheffield. We are currently preparing an air quality action plan
· Green spaces, parks and Move More – increasingly we are integrating physical activity into our broader strategic plans for example, as part of the “People Keeping Well” programme, in order to support targeted and more cost effective impact on both physical and mental wellbeing
· Inclusive growth – a healthy population is the key asset for a successful economy. Under the auspices of the City Partnership Board, we’re developing our approach to health, economy and social policy
· Ageing well – we need a refreshed approach to healthy ageing, one which sees Sheffield as a city for all ages.
The path to improvement is not straightforward or simple
‘adverse childhood experiences’ (ACEs)
I look at ‘adverse childhood experiences’ (ACEs) and why, during the early years of a child’s development, such experiences can have a significant and lasting impact on both short and long term outcomes including chronic ill health, unhealthy behaviours, use of health and social care services (and wider public services) and future life chances such as educational attainment, employment and crime. There is increasingly good evidence of a high rate of return on investment from interventions to tackle ACEs as well as increasing public awareness of ACEs and their long term consequences.
The key priority for the city will be to build this evidence into our existing service model. Sheffield is well placed to respond, and there is a need to build the science into our current models of services and policy, rather than build a new model. This obviously needs to incorporate interventions to address what can be done at individual, family and community level. We should also think about how to respond to those that have experienced it, and there is much to be learned from trauma informed mental health care.
mental health and wellbeing
I also considers why good mental health and wellbeing across the life course is so vitally important to overall health and wellbeing outcomes. The underlying meaning of “parity of esteem” between physical and mental health is widely accepted; achieving this in practice is more challenging. Focusing solely on mental (ill) health services is necessary but not sufficient to achieve the improvement in mental wellbeing that is needed. We need to prioritise mental illness prevention and promotion of wellbeing with the emphasis on population and community level resilience and risk factors. The economic rationale for this approach is also increasingly well evidenced and the report calls for a review of the Sheffield mental health strategy and related approaches to ensure we are making the most of this.
Of course we need to stop things going wrong, reduce the severity when they do, and provide high quality care. We should not assume however, that good mental wellbeing outcomes can only be achieved through better mental health services. If we over focus on “treatment” when people have an illness, we may never make the improvements needed to mental health. This will require a significant increase in focus on mental illness prevention and mental health promotion. The five ways to wellbeing for example, offers a good framework for this at individual and community level. There is a need to go further and consider how best to respond to or prevent the mental health risks or promote the benefits of broader social policy developments including debt, financial inclusion, welfare reform and inclusive growth.
Thefinal section of the report considers the impact of the rise in the number of people with more than one long term condition (such as coronary heart disease, diabetes or serious mental illness), known as multi-morbidity. We are beginning to see both an increase in prevalence of multi morbidity and earlier onset. This means we are developing more severe ill health earlier in our lives. This leads to a longer time spent in poor health and more “unhealthy person years” in a fixed capacity system that is designed to respond to single diseases and acute health problems. There is very good evidence that if we can shift the whole multi morbidity curve downwards we can expect to make significant reductions on pressures on health and social care services at the same time as improving health. The priority is system and population wide adoption of prevention approaches.
Available evidence and experience would suggest solutions to this issue rely on a far greater emphasis on and investment in primary and social care, mainstreaming person centred care, fully addressing the concept of healthy ageing as a long term investment and a move towards viewing healthy population as a critical infrastructure project for a vibrant economic and socially just society. The obvious objective is the bend the multi morbidity curve, prevent illness and slow or avoid complicaitons instead of developing your first long term condition in your late fifties, you develop it in your sixties instead as well as having fewer long term conditions overall.