Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence, December 11, 2007
OTTAWA, Tuesday, December 11, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:05 a.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
The Chair: Dr. Adshead, we are truly looking forward to hearing what you have to say and we feel we can learn a great deal from you. If you are ready, please go ahead. We will have some questions for you when you have finished.
Dr. Fiona Adshead, Director General of Health Improvement, U.K. Department of Health: I will respond to the questions that you have asked first, but obviously I am happy to answer any questions in more detail.
In terms of how to unite departments across the government, the key issue has been the leadership of the finance ministry, our Treasury. In 2002, the Treasury carried out a cross- cutting review of government, looking at what each government department and ministry could do to tackle inequalities. They based this on the evidence of Sir Donald Acheson's review, but they looked specifically at what needs to be done. They used it to assess their funding decisions in our next government-spending round. The Cross-Government Action Plan to Reduce Health Inequalities was published in 2003. My Treasury colleagues who could not be here this afternoon asked me to emphasize that the way we do our funding round is then to set cross-government targets for delivery. We have recently changed these even more to essentially bind government departments into joint action on inequalities.
Essentially, we had a cross-government strategy which required each department to act. We have also agreed on public accountability using an annual report that updates how far we got on that action plan. An independent, scientific committee chaired by Professor Sir MichaelMarmot reviews that plan. That report is for them to comment on government action. Our most recent report is coming out in the spring of 2008.
That is how we got cross-government action. Since we began, we have used cross-government mechanisms to bind action together. Politicians meet in our cabinet to talk about public health. The focus of those meetings has also been on inequalities. As director general, I chair a group of officials along with my senior colleagues across Whitehall. Again, we are looking at what we do. As we move forward on government action and the most recent planning round we have just completed, we agree with officials how we will continue joint action to address inequalities.
In terms of whether what we say we will do counts, apart from the status report I mentioned there is also an agreement between the Treasury and each government department to a quarterly review action against the targets. We put a report out to them telling them what we are doing in the Department of Health and that education will do some of the things. For example, what they are doing on the status of education attainment. Therefore, the Treasury holds each of us to account. In the future with our new spending round and our delivery targets, that will be done through joint program boards. That is what happens at present.
Let me move on to some of your other questions regarding the mechanisms we use to facilitate monitoring and action planning. We have targets for 2010 on life expectancy and infant mortality. We know that much of that needs to be delivered through our local governments. We have done a lot of work through our high-multiple operating frameworks to encourage the link to do joint action. We have a very different system from Canada in the sense that, in the Department of Health, we set the standards for what we expect the NHS to do. Following that, we outline in greater detail how we expect them to do that at a local level. Therefore, it is up to them as health organizations to commission with local government action. What we put in place focuses on the key priorities for the all the services.
One of the four priorities for this year is inequalities in health. We have developed a modelling tool that allows our commissioners to look at the interventions needed for their population at a local level. For example, we know that to stop early deaths from heart disease by 2010, people need access to blood pressure treatment, to reduce their cholesterol and to stop smoking. This tool and kit enables that intervention.
Our ministry sets the priorities for local governmentand ensures us that inequalities for health are at the top of their agenda. Planning at a local level between the hospitals and local government has been aligned. In the future, we are bringing that together more clearly in the spending round to create a single set of shared indicators in government and within the health service. Action on inequalities, such as action on housing and education affects mortality. There is a strong focus on joint action.
To look more broadly at what has made a difference regarding inequalities, political leadership has been key. We are pushing it to the top of the agenda. Our previous Chancellor, now the Prime Minister, and the then Prime Minister spoke about inequalities being a key issue and shows that social justice is very important. We put a lot of effort and resource into developing an evidence base to support this.
It has been important to look at how we can develop practices across local government based on what works at a local level. Having clear targets set at a national level for the government as a whole has galvanized action. It is also necessary to have a mechanism to check delivery.
Although we have all those things in place, we should emphasize that this is a very long journey. Our latest figures suggest we are only beginning to close the relative gap between rich and poor on infant mortality. This is the second year in a row that has been true.
On life expectancy, thegap is increasing at a national level. At the local level, we see that some areas are succeeding with those priorities and therefore, we are putting more emphasis on what actions there can be at the local level. We are finding that it is about partnership and shared leadership across the system.
The Chair: Thank you, Dr. Adshead. You opened by saying that you were able to get your finance department to distribute the funds in a way that united the departments.
In Canada, our situation is a little more complex than in the U.K. because we have another tier of government that you do not. Those are the provinces. They are particularly important with regard to health. However, we do have local situations that are quite different from province to province and municipality to municipality.
I would like you to tell us how you have made your financial policy work at the local level.
Dr. Adshead: I understand the difference between our systems. While there are big differences, we are moving to a more devolved model where as a government we set the high level indicators for action at the local level.
We have done a number of things with local government to raise this up the agenda. It might be helpful if I describe them.
There is long-standing interest in some local authorities on health inequalities. A number of councils have excelled at this in terms of action. We have termed them beacon councils. They have spearheaded the way for their colleagues to demonstrate that action is possible and they show leadership. That has been important in winning political hearts and minds to support this agenda. It has also been important to outline the specific interventions needed to invest at a local level.
We did a review of our target a couple of years ago. We found most areas were committed in principle to social justice and tackling inequalities and would be prepared to put investment where needed. The issue was that they did not know what they should do and what interventions should have the highest impact.
Across government, we have been re-emphasizing what needs to be delivered through each area of social policy. We have been clear with our health service about the exact interventions. There are others they can take, but if they want to put their resources behind a few things, that is specifically what should be done.
We also developed leadership programs. We have a national agency working with local government that supports them on their agenda. We have worked with them to develop leadership with local government for health and health inequalities. Local government themselves have produced benchmarks on what «good» looks like if they are going to tackle health inequalities. They do peer-based self-assessments to determine if they are doing the right thing. We have addressed things on a hearts and mind basis and give support on leadership.
Our national support team is a professional group of people from local government, the health service, and other partners. They do a reflective assessment of what has been done and will listen to the local situation with the local authority and health service colleagues. They will suggest a plan of action for investment that is done with the local organization.
Those are the key mechanisms we would expect for every community. Increasingly, more emphasis is placed on local communities deciding what they need most. We have tried to set the standards and a clear framework that the evidence supports for the greatest impacts.
Senator Cook: From a structural viewpoint, I would like you to explain more fully about your health inequalities unit and your local area agreements. Are they facilitators or is there an authority there? I am trying to interface the two levels of governance and to see if there is an option.
Also, do you have outcome evaluations? Finally, what is the responsibility of the national government? I am trying to establish linkages along the continuum to get to the person.
Dr. Adshead: Our health inequalities unit is a team based within the health ministry. They are responsible for policy development and supporting delivery of health inequalities policy.
We are currently considering whether we should strengthen that by having more cross-government presence. Our chief minister for health is doing a review of inequalities at the moment to see how we can improve what we are doing. That is one of the things on the table.
There are examples across government — both for climate change and something similar we are currently doing for obesity — where having civil servants seconded in from other government departments, forming more of a joint leadership unit across government, is felt to be effective. They are looking at that model. At the moment, that is what we have. That unit starts with civil servants. They have core governmental and policy skills, but we also bring in experts in the field to work with them, and they work very closely with academics in terms of reviewing the strategy.
As to local area agreements, the local government is expected to form a local strategic partnership made up of the public sector, volunteer sector, and community and business representatives. For us, the latter would be something like the local Chamber of Commerce.
Initially, they were strategic leadership groups. More recently, they have been required to put together what they are going to deliver through a "local area agreement.''
Why what I was describing on the local targets and indicators is more important is that in the past, they agreed to come up with an investment package because they had to. Now what we are saying to our health service, and also to local government, is you share mainstream business to sort out policies and to tackle obesity so your investment needs to follow the strategy. Together, they are judged on the outcomes that they achieve. That is very different from having a talking shop, where you agree it would be nice to do something together on inequalities. They are now much more bound in. Their own performance, how they are judged by our regulators, depends on joint action on this in the future.
For local people, we have produced local community health profiles that provide residents with an idea of how their area compares for things like obesity, smoking and life expectancy. It is a snapshot, a simple profile of health, because one of the things we have been interested in is how local people get accountability from their local government on what they do and how they join together.
Through a local government act, we require local authorities and health service to work together on a joint strategic needs assessment, whereby they assess the needs of the local population.
The directors of public health are jointly appointed on a local government and health service, so they work across the local community. They produce an annual report. Within that, they can discuss issues — if they think it is a big issue at the local level and the scrutiny committee of local government should consider that issue. Again, the scrutiny committees are set up locally. They are backbench committees, if you like, of local government that consider the best interests of local people.
In a snapshot, those are the local area agreements. I hope that gives you a broader understanding of how that fits into the local government and the local partnership architecture.
The new framework that the finance minister set up and that we are focusing on through the operating framework, which is our planning document for the health service, is focusing increasingly on outcomes. The public service agreement — which is our jargon for what we at the Department of Health have promised to the finance ministry — says deliver improved health and well-being for all, it is now backed up by very specific indicators, of which there are about 40 at a local level. We are judged as local governments in the health service. Are we improving in all ages and causes at the local level? We have to be accountable for how outcomes at the local level feed through to outcomes at a national level. Our status report will review inequalities and will link that back to what we are doing to close the gap, for example, on life expectancy.
That then flows into how we are held accountable nationally. Basically, if the continuity from national government to local government does not add up, then we do not get the target delivery that we need. In a way, that is how it works.
The accountability at the national level is through answering the question: Are we delivering the outcomes we promised to deliver? It is done through political cabinet committees, as I have described.
In terms of how it reaches the person, we are trying to think about understanding the situation of local people. I have mentioned that we could meet our targets. What we did as part of that was go out into the communities and ask local people what their experience was around dying too young in their communities — what the issues were. What we found was a policy of aspiration. Very sadly, people in deprived communities said it is quite normal to die in your 40s and 50s.
Part of what we are exploring now for individual policy arms — for example, to help give up smoking — is exactly what is the experience in deprived communities around smoking. How can we understand where it starts and how can we motivate them to quit smoking and what are the barriers in our service system?
We have tried not only to think about how we understand things at a national level, but we are trying to tailor our services in a different way so that we make that connection between the big macroeconomic changes in terms of reducing child poverty, but link it to best access services in the public sector.
Senator Cook: Do you have any evidence-based information or evaluations of your outcomes?
Dr. Adshead: We do; the status report produced by our scientific committee each year links where we are in the outcomes with where we think it fits in with the evidence. For example, where we are beginning to show closure on the infant mortality target, they will then say, since there has been a reduction in child poverty, why is this not closing to a greater extent?
All the interventions I have mentioned — the package to prevent early death from cardiovascular disease — are based on the best evidence of what we think will have an impact. Our national health institute, which is the body that looks at evidence, is actually looking at inequalities. I have also reviewed specific topics around how you get, for example, people in deprived communities to give up smoking. We continually try to refine our evidence, but we are also looking at our targets in terms of how we can understand our success and failure based on evidence.
Senator Cochrane: Dr. Adshead, you seem to have a great organization and you are well connected with the various departments, which impresses me. I hope that we will meet with some success as well.
Many of my questions have been answered but I want to know what factors have contributed to the adoption of this pan-government policy?
Ms. Adshead: When our Labour government came into power over 10 years ago, it promised that it would return to the issue of health inequalities and social justice. If you look across government policy, the cross-government action plan on health inequalities is backed up by a whole range of issues around how to improve inequalities across social policy.
A key indicator is education attainment in deprived groups. The education ministry has a whole raft of policies that look at that outcome. In a sense, they are backed up. Political will was an absolutely key issue for us. Another driver was getting everyone together to review the evidence. I would not underestimate the importance of the finance minister and the Treasury's review of the evidence and what each government department must do. In a sense, that binds people into a shared solution. Of course, if the targets and indicators that each government department needs to follow and the money they get is linked to that, then that also binds them in. Political will to action, a shared evidence-base and targets that help the core purpose of the ministry are key.
It is important to emphasize, though, that other ministries might not necessarily think that some of the targets they have, whether educational standards or tapping into poverty, are about tackling health inequalities. Instead, they would think it is about their core business.
Part of the trick, and part of what I have learned, is that you need to frame tackling inequalities in a way that basically says to other colleagues: I can help you achieve your educational standards if you help us. It is a win-win situation because health outcomes, which are what health inequalities are about, is a key to the health ministry. However, it is only of secondary importance to an education ministry, no matter how much the government as a whole might wish to tackle inequalities.
Seeing how each government can act on things is very important. That is one of the reasons that when we reviewed the targets a couple of years back, we learned the lesson that unless we bind other ministries in the shared goal, we will not achieve those kinds of mutual aims.
A new performance matrix— our comprehensive spending review— will give you the kind of shared focus that had been lacking in terms of each having to deliver something for a common purpose. In the past it has been more about delivering your bit of the jigsaw puzzle. Obviously, it is open to debate, given that it is early days and they have only just begun this spending round, as to whether it will lead to even greater delivery.
Senator Cochrane: Did you find that some departments simply declared that they would not partake of the study?
Ms. Adshead: I was not around for the 2002 review, so I do not know. Basically, if the finance ministry tells a department that they have to undertake something, they do it. It was done with a political agreement across all departments.
Senator Cochrane: You have a real leader, I think.
You mentioned the 12 national indicators. Did you have to add more indicators after your study went forward?
Ms. Adshead: Yes, we have refined the indicators. We have the cycle of a spending round every two to three years. This time, we have refined the indicators from experience because, at a local level, we used to require people to monitor life expectancy. However, at the time between any action in the health service or local government between life expectancy and the local community changing, the service delivery is so long that it is not meaningful. We have adopted targets like all-cause/all-age mortality because it is much timelier and much more linked to action at the local level.
Each time the finance ministry decides how it will give its money out and manage across government, it decides on the indicators. The review that we did together on the inequalities targets a year or so back is fed into the spending review round this time.
Senator Cochrane: I am interested in your measuring progress. Have you been able to accurately measure the progress using the indicators that you have chosen?
Ms. Adshead: That is a very good question. I just described how we have used indicators that are timelier and more specific to local action, like all-cause mortality, for instance. The problem is that when the indicators at a national level, like the life expectancy target or infant mortality, change or do not change, the issue becomes how to link it to causality. That is one reason that is happening and why we have been trying to break it down more to a local level so we can understand where people are succeeding in delivering the targets, where they are not succeeding and then look at the methods of delivery.
We use the best evidence to model what we think would have the biggest impact. For example, we know that the life expectancy for smokers is the single biggest contributor to our gap in life expectancy; and we know it will hold true. The question arises at the local level and whether smoking in some communities might be less of an issue than in other communities.
That is why we have tried to model things at a national level and then link them down to the communities. The dilemma with any indicator, as you would well know, is that you measure what it measures, and many other factors might contribute to success. When our national support team does a review at a local level, it looks at issues such as how much the community has been engaged, the strength of the partnership working and how much commissioning of local services is actually related to inequalities. Often the indicators are not met because of some system problems, leadership and other factors with which you are familiar. You can measure it at a high level but you need to get beneath the data in order to understand what is truly happening.
The Chair: I would like you to follow up on your comments on education. Senator Fairbairn will be interested in this because she has spent a large part of her time in the Senate trying to deal with literacy in Canada. Educational levels, even in our complex mosaic of government in Canada, can be measured. We can measure how many people have primary, secondary and post-secondary educations. If we could apply one of your tool kits at the local level, we could measure the effects of the interventions on local education.
Would you expand on that? Senator Fairbairn will follow up in a minute.
Dr. Adshead: I should first say that I am not a specialist on education policy. At the moment, our tool kits simply focus on what our health service can do. They do not focus on education, perse. The kind of work we have been doing with the Department for Children, Schools and Families is around skills and health literacy. In England, we have a problem with literacy levels in the adult population. We know one of the reasons why people do not necessarily look after their health or go to health services is because they do not understand the need; they basically cannot read and write. What we have been doing is linking developing adult literacy with health because people are normally very interested in their health. It is often a way of de-stigmatizing some of the education interventions. That has been one approach. Generally, the education ministry has a whole raft of policies to improve statistics on math, reading, et cetera, at the local level. In deprived groups, that is the indicator we use at a national level.
Where we are trying to commission information at the moment, is how we could do economic modelling across social policy to look at how these things interconnect so that we know, for example, that if you tackle drugs and alcohol problems at a local community, you are more likely to improve health outcomes, as well as crime rates. We are looking at the relative contribution of that modelling.
The international evidence regarding education is very strong. The Commission on Social Determinants of Health, with which you are familiar, is looking at education as one of its prime areas.
Senator Fairbairn: I listened carefully to your words and was left virtually speechless in trying to get the sense of how you are dealing with the two very difficult issues of health and literacy.
I know that Britain has, in its recent years, done some extraordinary work on the literacy level with the mindset of knowing that if you have not dealt with literacy, then it is very hard to engage your population with these important issues. I am curious about the level of learning that people of all ages are dealing with in our country and in yours. It is not like a school project; it is far more difficult than that.
In particular, what programs do you have for seniors? It is very difficult on seniors who do not have significant levels of literacy in our modern age. It is difficult regardless of a government's best intentions and their efforts undertaken in health.
How do you join with the people on the ground in trying to reach out to that group? I am thinking of seniors themselves, and young parents raising their families. For seniors, life and health, et cetera, are fundamental issues. At the other end are young parents who are raising their families and may be experiencing a great deal of difficulty with literacy.
Dr. Adshead: Concerning schools, some of the work we have been doing on health follows some of the WHO approaches with the National Healthy Schools Programme. We have a target that, by 2009, all schools will be healthy schools. We have recently increased our standard recently of what that means. Healthy schools mean improved action on diet, nutrition, physical activity, personal education and so on. That creates the framework for some of the policy areas on improving numeracy and literacy levels within primary and secondary schools. We are trying to make the whole school environment a healthy environment, both for the pupils and also the teachers.
In addition, we have an extended school program. In this program, schools think about the role they can play in the broader community, and how they can improve facilities for families as well. As an example, parents have the opportunity to participate in health promotion.
You are correct; there is a big involved in getting young parents to understand that health issues are linked to literacy. Some of our health programs have actually focused on what is basically a "community mothers'' approach which is based around peer educators. Peer education is linked into mothers, which, in the package, improves health and helps understanding, including literacy skills. There have been some targeted programs in what we call Skills for Health or health-literacy programs, and we have targeted parents.
We have also been looking more broadly at how we make our health promotion messages more relevant to deprived communities. We recently launched a campaign developed for mothers in deprived communities to look at healthy eating.
The advice given was not something that a richer family would do. It is understanding the barriers the less privileged might face and then tailoring the health promotion messages to their own situation. An important issue has also been the average literacy in those communities.
Some of our health promotion work has also been linked into an understanding of where people begin in life. That has been linked into health literacy, as well.
In terms of seniors, again, the literacy programs do notdiscriminate on age. The sort of approaches we have been doing mainly around chronic diseases have tried to actually lean more towards self-care and how we can empower people to look after themselves.
We have developed things like the Expert Patient Programme, which basically develops the skills of individuals to look after their own disease. A lot of work we have been doing with the healthy communities is working with elderly people on how you present food to the community. Again, that has been an empowerment process for not only increasing community understanding but starting from where they are at. There are a few examples of this: Having slippers that do not fit well often leads to falls, improving the level of lighting at night, et cetera. The kinds of collaborative action programs I have mentioned have worked with people in their communities to actually get action to implement the kind of changes which works with and for older people and brings them on board. It is not about doing things to them but trying to do things alongside them.
Those are some of our approaches. I do not know if that is helpful.
Senator Fairbairn: It is very helpful, and it is also a very vigorous response. I regret to say we do not have at the same level in this country. Of course, this is a very large country and it is hard to reach everyone.
What you mentioned is being done with the schools and the parents sounds really first-class. However, I am still worried about the seniors who, very often, are not in a family situation. I think those are the people we worry about. They are at a point in their lives where health and all that goes with it, such as prescriptions and what you have to do, is critical.
Is there an outreach element in your program directed specifically to seniors, in their residences, to make sure that they have the background that will enable them to continue living a decent life?
Dr. Adshead: It is beyond my specific policy responsibility, but one of the key elements we have undertaken in recent years is to bring together health care and social care for older people. This is in an effort to get a more holistic assessment of their needs and more connected solutions of what helps them in their daily lives. Our minister recently announced that older people will be given the opportunity to direct the resources for their care themselves. For example, if they want somebody to help them with their cleaning, they can use the money to pay for that.
There is that outreach, particularly for vulnerable older people in communities. It is not part of our inequalities program, but it is part of the overall government response for older people.
Senator Fairbairn: Thank you very much.
Mr. Chairman, if possible, it would be interesting to receive from our witness the material showing how they deal with this issue. I know they do it well in Britain. It is tougher in Canada because we are a large country.
The Chair: Dr.Adshead's office has been tremendous in supplying us with material. I am sure she will supply whatever she can in that area too. I will be in touch with her further about that information.
Senator Brown: Can you give us an idea of the average patient wait times from diagnosis to treatment or surgery for chronic pain or health problems such as knees, hips, joints and back pain?
Dr. Adshead: The government has been keen in recent years to reduce waiting times. We have a policy that we are prioritizing to reduce all waiting to 18 weeks from the time a patient is seen to getting treatment in place.
I cannot remember exactly where we are on that, but we are making good progress. In the next two years we are to bring it down to a national standard. That is requiring a lot of coordinated activity on things such as diagnostics and all things that tend to hold people up.
I know that people's perception of the health service in England is that we have long waiting times. That is precisely why our ministers have put so much effort into reducing that time.
Senator Brown: Can you tell us what percentage of the U.K. health budget is consumed by administration and what percentage goes to the doctors and nurses that provide the actual patient care?
Dr. Adshead: I am afraid I cannot off the top of my head. The majority of it goes to patient care. I can find out for you, but compared to some other health systems, we have a relatively small proportion going to administration.
Senator Brown: Some of your health care is famous around the world. For instance, the Birmingham hip is a replacement for people who have degenerative hip joints. I know people in Alberta who have gone to England to have hip replacements and were extraordinarily pleased with them.
I want to know if that is also available to the general public in Birmingham. If they wanted to have a hip replacement themselves quickly, would they be able to do that?
Dr. Adshead: They would be subject to the 18 week waiting time commitments I outlined. It depends, essentially, on their local commissioner.
Senator Pépin: Bonjour and thank you for sharing your experience and successes.
In Sweden and Quebec, legislation requires that health impact assessment be undertaken when new legislation or regulations are brought forward. Could you tell the subcommittee whether health impact assessments are required under the program for action, and if so, how many assessments have been performed since the program was announced?
Does the agency actively engage in health impact assessment?
Does the Department of Health or another agency provide support for the departments that are required to complete health impact assessments?
How do you ensure that assessments are taken seriously by non-health agencies and not simply regarded as an additional administrative afterthought to policy and program development?
Dr. Adshead: In our 1999 government white paper on public health, there was a commitment to do health impact assessment across government policies. In reality, nothing really changed. Therefore, in 2004, when we did our follow- up public health white paper on government policy, we also made a commitment to health impact assessment. However, this time we gave the cabinet office responsibility for coordination of policy assessment.
When any law goes before Parliament, there is a process of regulatory impact assessment. This is jargon for looking at how that legislation is going to have an impact across government ministries and all businesses, for example. I am not aware of any ministry that has looked at health as a key issue as it has gone forward. It is only best practice. Ministries are not required to do this. We have looked at what resources would be needed, and we have talked to the government school, which trains civil servants, about what it would require. We have assessed that. It would require a resource to give advice on how policy would impact on health.
When I do an assessment in legislation I put forward, I have to do an assessment on how it would impact on local businesses, for example. I would have somebody to go to within another ministry if I want advice on how we frame that. The ministries themselves would come back and comment on it.
I think work is taking place called strategic environment assessment, where we negotiate whether health ought to be part of what is taken into consideration at a local level; for example, when planning applications go forward or when big developments happen within local communities.
That is under discussion at the moment. We have had a committee that has put forward a report on what the government should do — health impact assessments, all their policies — and the recommendation was that they should. I am afraid this is an area where we have had good intentions — we have tried to integrate health impact assessment into best practice — but the reality is that unless you have something to drive this forward across government, the resources within the civil service or through other means, it tends not to happen.
The Chair: Thank you very much, Dr. Adshead. We were under the impression that Mr. Earwicker was going to talk to us about the health inequalities and social determinants specifically, since he is the coordinator of that program. Is he coming, or will we proceed to question you on that area?
Dr. Adshead: Unfortunately, he is unable to be here because he is doing an urgent briefing for our ministers. If you want to talk to me about it, you can. I will do my best to answer.
The Chair: This is of enormous interest to us in Canada. In addition to the dozen or so determinants of health recognized by yourselves and the World Health Organization, we have another determinant in Canada, which is geography. Some of our people, particularly those who live in the North, have very poor health status.
When our committee embarked on this topic, our interest was to try to identify these areas and the tool kits that could bring together the resources in these areas. The people in the North do not have access to good food in the winter months. They need assistance with housing, sanitation and appropriate food. We would like to elevate their health status to the mean level in Canada.
We are grateful because Britain has established so much in this area. I had the great pleasure of participating with Sir Michael Marmot in Vancouver last spring in a symposium for the world health authority.
However, let me bring you back to this point. As far as I know in Britain, you do not have the disparity we have in Canada. You do not have the extremes of inequalities in health status that we have, but you must have significant pockets of poor health and health inequalities. How do you move in with the organizational knowledge you have now and get on the ground locally, address the dozen or so determinants and move toward correction of these and measure your outcomes?
Dr. Adshead: Are you asking what it is like at the local level?
The Chair: Yes.
Dr. Adshead: Before I did my current job, I was a director of public health in a part of London that has some of the highest levels of deprivation, along with some of the highest levels of affluence, which is not atypical in Britain. There are parts of the country that have high levels of deprivation that are more uniform. However, quite often, poverty sits alongside affluence in the way our society is structured.
The way we have developed our programs, and the priority we try to give inequalities, is designed to help deliver at the local level. When you are thinking about what that means, if you are responsible for a local community, it means exactly as you suggest — understanding what is going on in much more detail. As part of our policy, we look at what we call our «spearhead areas.» They are the fifth-most deprived local government areas in the country. A lot of the way we target our resources is toward them in terms of money and new programs.
In reality, the number of people who are deprived and really suffer the inequalities we have been describing are more universally distributed throughout England. One of the challenges we are looking at as we develop our inequalities action plan is how we can get down to that smaller level.
In electoral wards — a lot of smaller, local geographic areas with perhaps a few hundred people — they will do the kind of analysis that looks below the big population. They will know that particular housing estates have high levels ofdeprivation; they will know GP primary care practices that have very deprived clients. A lot of our work tries to get beneath the picture. The trick with inequalities is not only to understand communities at the very local level, but also to tailor interventions to who they are as people. If there is a particular ethnic minority group, it is really important to understand the specific issues they face and their own health beliefs — why they think they have diabetes, for example — and how that relates to how you can treat them better and the services they receive.
Some of the programs that have been working nationally use social marketing, which is basically to use that kind of ethnographic and inside work to advise local communities. There has been some work in the northeast that has looked at mothers in deprived communities who smoke while they are pregnant and how you can design services to help them give it up.
There is another program in London that has looked at using a local boxer who is a hero for the local deprived communities — to help people give up smoking. They also have targeted news agents who sell cigarettes, to do campaigns at the shops where people go to buy cigarettes and to target the brands that people tend to smoke.
The key is to understand who you are dealing with and then target services around who they are and how you get to the direct needs they have. That would be true in rural areas, because although we do not face the geographic issues you face in Canada, we do have communities that are more isolated within geographic patches. That form of approach has to be to join our public sector services to reach them in a different way. I do not know whether that helps to answer your question.
The Chair: It helps a great deal. I mentioned the complexity of our government in Canada. To compound that, we do not have enough public health officers. We have many vacancies. For example, there are 47 municipalities in Ontario. I do not know the number of public health officers there are, but probably half of those municipalities do not have a public health officer.
We are trying to think through and design a framework to recommend to governments for action at the local level — the kind of action that they are instituting in Britain — and I wonder if you could help us.
Are you using your local public health officers in this implementation, or are you using local governance? Obviously, you have to get the people who are in charge of housing and so forth. How are you approaching that?
Dr. Adshead: We are using both local public health officers and local governance for the reasons that you identify. In terms of local directors of public health and local public health offices, we run public leadership programs. In the last five years, we have expanded the nature of public health offices to take people from a broader range of backgrounds than just medicine. Our directors of public health come from a broad range of backgrounds but they have to complete the same accreditation. We make a great effort to recognize people who have worked in public health for a number of years. We have been working to diversify our work force because we have some of the same issues that you have in terms of vacancies and insufficient capacity.
We have also been looking at how to work with universities in getting a broader range of graduates interested in public health. Recently, we set up a program called Teaching Public Health Network where undergraduates from a broad range of disciplines, such as architecture and others, are exposed to basic health principles to have a broader understanding of the field. We hopethat people will champion health as a part of what they want to do because they understand its importance to broader society.
We have also worked with an organization to develop leadership programs for politicians in local government and for officials in health inequalities on how to improve their skills and understanding to give them an opportunity. We have been trying to work with our environmental health officers to develop skills. We have some of the same problems in some of the approaches.
As well, our local directors of public health and our commissioners of public health have a joint responsibility for health in local government so we have tried to encourage a joint approach to leadership for health issues.
The Chair: In many of our municipal governments, the public health officer has a seat on council. Do your public health officers sit on local councils?
It is important for us to know how we can apply a tool kit such as yours at the local level. I agree that everyone in this field must act locally to get the best results. At the very least, there local action must be integrated with national action.
Does your public health officer do the coordination locally, or does the local government coordinate? If the latter, does the public health officer sit on the local governance council?
Dr. Adshead: In about 70 per cent of situations, the director of public health is jointly accountable to the chief officer of the local government and the chief officer of the health service. We are trying to promote models where there is a direct accountability across both local governments and all its public services and the health service. We are trying to move toward that because public health cannot only provide leadership for the programs but also it has the key technical skills to help deliver them. However, as I have described with the joint assessment, we require that the director of public health and our director of social services, who normally works for local government, carry out this joint strategic needs assessment. We have not only identified the individual but also we have bound that individual into the commissioning process, the assessment process and how that links into our local area agreement. The individual becomes aware of how the money is spent and how to deliver the targets. It happens through the individuals in terms of their leadership role and their position in local government and health authority. It is also linked into the systems by which the organizations do business. We found in the past that where it works well, public health works swimmingly. Where there is a problem, we have found that either the leadership or the organization does not want to do it themselves, and it does not work.
We have tried to create a safety net that is built into how the organizations do business. If they are led by someone who is a specialist or public health expert, then it does not necessarily become their mainstream business. One of the dangers of that model could be that the director of public health will tackle inequalities for us, where, of course, it requires the commitment of all local political organizations to make it happen. Our approach is not to undermine the leadership role of the public health directors but rather to ensure that all the pieces of the jigsaw are in place to ensure their leadership is most effective.
Senator Cochrane: Are your deprived areas allocated more funding than other areas to achieve some benefit in tackling the disparities that occur in such areas. If so, have other agencies disagreed with providing more funding to those areas?
Dr. Adshead: The money for health service funding is weighted by deprivation and the age of the population. In 2004, when we were reviewed inequalities and prepared our public health paper in choosing health, one part was to review our resource allocation formula for health services. The bottom line is that more deprived areas get more money to spend on their health services because they are deemed to have more need.
That would also be true, to some extent, for local government where some of the allocation for other public services is weighed according to need and deprivation. I think the debate often comes within funding areas where you have a more affluent area and a more deprived area. This is often the case in local areas. The logical course of action might be to redirect services to the more deprived areas because there is a greater level of need. That is often where the disagreements arise as to how you best target resources within an area.
Obviously, whenever the funding formula is debated nationally, there is a big debate between the different areas— the more affluent, the more deprived— as to the final formula. There are arguments that urban areas, such as London, need more funding because of their historic provision of health services. Like any country, there will be a debate as to the right level of need and the right thing to do about it. Traditionally, since the 1970s, our funding allocations for the health service have been weighted to the more deprived areas.
Senator Pépin: Could you tell us more about the role of the Health Inequalities Unit, particularly, how this group coordinates efforts within the central government?
Dr. Adshead: As I mentioned, there are teams responsible for delivery of not only a policy but also delivery of the national targets. What we have done, as I have described before, is to work through a cabinet committee of ministers, which we support. We also have an officials group at a high level below the head of the Civil Service Department, which I chair. I have senior members from across government, as well. That is the mechanism we use.
As I mentioned earlier, we are looking at how we can improve that model. If an area has a high priority, which it does for us, it always needs more resources. One of the questions is whether we should get civil servants from other departments to work with us, which is something we are looking into now.
The unit works through a committee structure and through the finance framework that I described earlier. It works through all the different policy areas that contribute to getting the job done, whether it is educational standards or housing. To some extent, it is done within the strategic framework. When we review the policy areas in the annual report, the government departments will obviously contribute to the outcome.
How to go about making things work across governments is a difficult issue. We are reviewing how we can improve that even further.
Senator Pépin: Hopefully you will be able to solve the problem. Thank you.
Senator Fairbairn: You are educating us very well. I want to ask you about another part of society with which Canada and, indeed, all countries, have difficulty. That is the street people, or the people in the larger communities who have severe health problems based on many other social issues. I am wondering if this falls within your broad efforts of outreach. Certainly, in the larger cities in your country, you must have this problem. Even in rural areas and in small towns, these issues are rising, to the great anxiety of families and the local government. How do you deal with that problem and where does that group fit in?
Dr. Adshead: That would be the responsibility of the local government. A number of years ago, one of the things that the Labour government did as part of their social justice agenda was to look athow they could get people off the streets and into hostels. Additionally, they examined how they could improve services. I am afraid I am not up to date on where that initiative is now.
A few years ago, when I was the director of public health in a local community, about 10 per cent of the population was what we termed "homeless.'' We looked at how we joined up services with local government and how we worked with hostels to improve timely care so that, often, there were nurse-led primary care teams that would go into hostels. There was a particular issue we had with suicides in those hostels, so we looked at how we could deliver services.
What typically happens within our new system is that local governments will work with the health service with education, if appropriate, and with families with young children to look at how services can be joined up to deal with what can often be a very difficult and vulnerable group of the population.
There has also been work in this country looking at people who are in temporary accommodation who would not be classified as street homeless. Nevertheless, particularly with families and young children, there are problems with living in an area for a short time and the how that disrupts the children's education. There has been work on that, but I am not responsible for that policy area. I hope that gives you a flavour of some of the things that happen in local communities.
The Chair: I will bring you back to the cabinet committee, which is a truly phenomenal accomplishment. I do not know how we will accomplish that here, but we will have to try.
I am sure you are familiar with the Swedish committee setup, which is very similar to yours. Can you comment on the similarities and differences between your systems?
Sweden has developed such clout that, for example, when the local authorities are planning a new housing development or new roads or bridges, they have to go through the population health authority and get some type of approval. I do not know who carries the strength in the final analysis, but they must get some kind of approval to proceed so that they are not carrying out projects that are damaging to population health.
Can you enlighten us on this and tell us whether there are any similarities between your two systems?
Dr. Adshead: At a national level, there is the cabinet subcommittee. Our new government is establishing the formats of health. I will talk about what did happen rather than what will happen.
Our Deputy Prime Minister chaired that subcommittee. We had representatives from most of the main ministries. It was an opportunity for us to look at how the ministries contributed to the overall delivery of public health and health inequalities as a subsection of that delivery. When the reviews were done, as I described, that committee looked at them. They would take concerns back to their ministry if there was an issue where something was not working.
At a local level, the same thing does not exist for Sweden. The local strategic partnerships would look at major policy issues across a local area, and there might be an opportunity for discussions regarding whether new road developments or a new building would affect health. However, it is not the same thing.
I mentioned strategic environment assessments to one of your colleagues and what we are hoping might happen there. Health would be considered alongside environment and community impact amongst other things, but at the moment, the same considerations do not exist.
What does happen is that some local authorities and local governments do inquiries as part of their scrutiny function on specific issues. They may carry out an inquiry if there is, for example, a rising rate of tuberculosis, or drug problems.
In particular, they would look at issues across the whole system. Therefore, it may be around how the prison service works. It would be a very broad-based inquiry. That kind of scrutiny can be triggered by local people. Part of the new Local Government Act looks at how local people can petition for more local government action.
For public health, we do not have the same kind of mechanisms that you describe in Sweden. As a professional, I can definitely see the advantages to that.
The Chair: For example, do they consult you when they decide to put in another terminal at Heathrow airport?
Ms. Adshead: Normally, there is a cabinet clearance process that happens across government on major policy issues. A major policy will go around to each of the ministries, and in practice, ministries that are directly impacted by a policy would comment. For example, if our Home Office were doing something on prisons, the Department of Health would respond since we provide drug treatment services. The Home Office will consult us concerning those changes.
The level of official involvement varies according to the policy. For most major government policies, different departments will be asked to comment and raise any concerns or any impact it will have on them as a ministry. In reality, both at local and national levels, it boils down totwo things: Relationships are established across ministries between politicians and officials; and the resources available to get that engagement and look at issues.
From my perspective as a policy developer, there are many government policies in which I would like to become more actively involved, but we do not always have the resources or the civil servants to do that. It is more about the feasibility of having the time and the resources to comment on things. If you are going to do it effectively, then you need to invest. That is why the Office of Climate Change has been developed. It is recognized that to do this effectively across government, you need to resource it.
Senator Cook: If I understand you correctly, the bureaucracy across governments works on plans and policies. Do you have adequate human resources to deal with the implementation of that service? I am thinking of doctors, social workers, educators, nurses, et cetera.
Ms. Adshead: You identified a key issue.
We have been trying to move away from telling people how and what to do at a local level and to minimize the number of instructions. It may not sound like that from the evidence I have given, but we are going in that direction. For example, over the last 10 years, the number of national targets has gone down from hundreds to 30 commitments, which is a massive reduction in the number of priorities. It also reduces the number of indicators, or targets, that a local government looks at.
There have been various estimates as to how many there were, but they have gone from somewhere in the range of 600 to fewer than 50. More emphasis is placed on giving people the opportunity to use the resources they have to tailor it towards delivery.
In public health terms, there has always been an issue whether we have the right number of people to do all the tasks. Any professional group will say that they do not. We have been trying to encourage working together to get greater efficiency from public sector resources and to look at the required skill mix. That is, can you bring in less- skilled workers to do jobs traditionally performed by doctors? How can you use the available resources in the best way?
What we say to the areas is here are the resources you have. Here are the high level targets we want you to achieve. It is for you to think about how best to use those resources.
As with any country, there will obviously be a debate and comments from our middle tier, which would be similar to your provinces. They question whether we are giving them enough resources and what they can deliver with them.
The Chair: In Canada, it would seem to be a relatively simple task to fill all of the public health positions in the provinces. They cannot be filled with doctors because there is a tremendous doctor shortage, particularly family physicians. I do not think they can even be filled with nurses because of a nursing shortage. However, the collective clout of the doctors and nurses is such that they cannot be filled with anyone else.
How are you dealing with that situation in Britain?
Ms. Adshead: We have the same problem which was why we went through the process of developing a multidisciplinary workforce. In 1999, our white paper on public health talked about the need to develop public health. Over the past 12 years, there have been some very painful discussions between our medical trade union and our Faculty of Public Health, which is our national body that sets the standards for professional training.
First of all, they addressed whether anybody other than a doctor could hold a leadership position in public health, be our director of public health, or even be a consultant. That took a number of years to get agreement, and there were a number of professionals who championed moving towards that agreement. One of the big debates was how you can be sure that somebody from another professional group would have the same standards as a doctor in public health.
We developed training programs which take people who have a degree and established criteria about who can become an entrant into public health training. They go through that training and at the end have the equivalency to a doctor who might enter for an emergency specialty. They train alongside them. This also includes nurses.
We are on a journey to establish a regulatory mechanism for non-medical public health specialists. We set up a register for people seen to be equivalent. This is done on a voluntary basis, with our professional faculty who police standards or appointments. We require anybody who wants to be a director of public health to be registered with this voluntary register.
For example, a person who has been working in public health, but has not been recognized as a specialist for a number of years, can be tested to receive equivalence with a doctor. They would have to take an examination. They have to keep up the same professional development once they are on the register.
It has been a difficult process because at the beginning of it, doctors thought they were going to lose their jobs, and nurses were not even recognized at that point in the process. There has been a separate process for public health nurses — for example, people who come from a health assistance background, who have worked with families and children — whereby they can become what are termed «consultants» in public health nursing, and they have a different level of expertise.
That is some of what we have done, but it is a difficult process with many challenges. Upfront, as a government, we said that we expect this workforce to be multidisciplinary and that led to a broader process. However, some of these discussions have been going on before that was initiated by the government.
The Chair: Thank you very much. Senators, I do not have any more questions. With that, I cannot tell you how indebted we are to you, Dr.Adshead. You answered all of the questions we had very clearly and directly. We have imposed on you a great deal and we are grateful to you for coming before us.
Ms. Adshead: Thank you, and good luck.
The Chair: We will meet tomorrow at 4 p.m. We will have witnesses for an hour and a quarter and we will take 15 minutes to discuss our Cuban trip at the end, because the staff is meeting with the Cuban embassy this afternoon.
The committee adjourned.