Monday, 14 March 2011

Visiting Durham

Interesting trip to Durham in the North East. I had been invited by the Vice-Chancellor of Durham University to give a university lecture. It seemed a bit bold, but I made a condition. I pointed out that we were actively trying to involve communities in uptake and implementation of the Inequalities Review, including in the North East. How about using the occasion to engage stakeholders locally who may play a role in taking the agenda forward. He did.
My lecture, billed as A Fairer Society for a Healthier Future was well attended – they announced that the University wouldn’t allow standing room only, although there were a few standers in a packed rom. Following the lecture, there were some excellent questions and comments including:
·         The Marmot Review emphasizes social justice, good; but it does a totally inadequate job at dealing with ethnic specific health problems, and the whole question of racism and discrimination. I referred to the research (by James Nazroo) that shows that much of ethnic differences in health are socio-economic. That said, I agreed with the questioner that we had not given much emphasis to questions of racism and discrimination. Certainly, we had heard from Gypsies and Travellers that they did not recognise themselves in the Report.
·         A representative from a faith community asked by what right did people expect to be able to exploit their natural gifts in the market place. He wanted to open up the discussion in a more fundamental way. I agreed that such discussion needs to be had. When Mervyn King, governor of the Bank of England,  expresses surprise that the public have not become more angry that they have to suffer because of bankers’ excesses, it is time to take notice.
·         During my lecture I had asked if anyone thought other than that much of global health inequalities was in principle preventable. The questioner asked: Every one may know, but does any one care? Indeed!
·         Creating jobs was, of course, important, but creating healthy meaningful work was part of development of social capital. Agreed. I reported what we had heard in Malmo last week: that in the poorest part of the city, with large immigrant populations, unemployment was at 60% for men and 65% for women. As part of Sweden’s million homes programme, there was a proposal to teach people building skills, to make them more employable with all the benefits entailed, and have them involved in building local housing.
·         Part of dealing with the causes of the causes is dealing with the political drivers of the causes of the causes. Agreed. By all means, use the evidence brought together in the  CSDH and the English Review as the basis for a more political analysis and action plan.

 After the lecture and Q and A, there was a policy seminar involving about twenty people from local politics and local government, the health sector, and the university, deftly chaired by Stephen Eames from Co Durham and Darlington NHS Trust.
What struck me was that despite an abundance of reasons for gloom – deprivation and inequalities in the North East, savage public spending cuts, non-stop reorganisation –the seminar participants were not gloomy. The tone was constructive, forward-looking, even optimistic that they could make a real difference.
Three priorities for future work were identified:
·        Early childhood, including mental health
·        Older people
·        Taking the English Review’s six recommendations and shaping public health strategy accordingly.
It was also pointed out that they in Durham and the North East could have an important advocacy role in influencing national policy.
My reactions to the discussion:
·         I was delighted with rhetorical question asked by one: Do we need to be well-informed to be fair. Be a good question for an entrance exam to University. As someone who has spent a great deal of time compiling evidence, my answer, of course, is yes. But I suppose if  you thought that consequentialism was the work of the devil, and fair process was everything, perhaps not. But how would you recognize fair process without good information?
·         A key message that has come through to me is the importance of doing things WITH people not TO them.
·         The public slanging match – Private good, public bad, or vice versa – was not a helpful way forward however useful such simplistic slogans were for politicians. (It was put to me afterwards that I was needlessly disrespectful of politicians as a class. I was contrite and apologized for being simplistic myself)
·         We need an examination of what has worked and, in the future, what does work. Evidence!
·         If, in Durham, they are serious about taking the Marmot Review agenda forward it would be excellent if they set up a mechanism to plan, execute, and monitor. We would be delighted to be kept in touch with their progress.

Wednesday, 9 March 2011

Second European Review meeting in Malmo, Sweden

We held the Second meeting of the European Review of Social Determinants and the Health Divide in Malmo.
When we began the global Commission, the CSDH, we asked ourselves what success would look like. It never occurred to me to answer: a Commission being set up in Malmo. But that is what happened, and is an undoubted benchmark of success.  A city employee, Anna Balfours, read Closing the Gap in a Generation. She said it spoke to her. They invited Denny Vagero, a commissioner in the CSDH, to give them a seminar. Anna said: as an Englishman you like to hear a British correspondent reporting from abroad. Denny was their foreign correspondent from the world of global health and they took the decision to set up a Malmo Commission to translate th findings of the CSDH into a form suitable to address social determinants and health inequalities in their city.  
The European Review meeting was hosted by leaders of the city of Malmo, who were hospitable, generous and constructive. Their Commission for a Socially Sustainable Malmo, chaired by Sven-Olof Isaacson, was launched with a press conference on Wednesday afternoon, followed by a lecture from me, chaired by the deputy mayor, who is a member of the Malmo Commission. We then had a round table with the Commission on Friday afternoon as a way of cementing their partnership with the European Review. We had a good meeting. It warmed the cockles. On the second morning I felt the Review suddenly took off, caught fire, came alive. It was, and is, exciting. The first meeting had been in Madrid in October. There had been such delay in getting started that we began without contracts having been issued and with difficulty getting everyone together. The first meeting felt a bit anti-climactic. Our task groups, 8 topic groups and five cross-cutting, were to do the work of assembling the evidence about proposals to reduce inequalities in health and the social determinants across Europe. But without contracts they could hardly be expected to function properly, which meant our whole timetable was in danger of slipping.
In the event, the Task Groups have done a terrific job of producing interim reports with outlines of their future work. They were at somewhat different stages, some with draft chapters, others less sure of the scope. But on the whole it was very reassuring. We will have real substance, new evidence and proposals on which to draw and to deliberate. The Senior Advisors got engaged at a private session. They discussed:
·         The report: audience, how political it should be, what is the narrative
·         The conceptual model – they didn’t like the CSDH form of it. The general idea of social determinants as the “causes of the causes” is accepted, but getting it down on paper in a useable form is a challenge
·         We re-emphasised that the Review has to deal with inequalities within and between countries
·         Europe has special features because of the European Union and the European Court of Human Rights.
·         Partners: countries, regions, cities and sectors, including the private sector
·         Should the output be approaches or specific interventions?
·         The subjective reaction of people is important as is the more objective indicators. This implies enlarging the focus to include well-being.
The meeting moved the Review forward intellectually, practically and we have found a wonderful city partner to help shape our endeavours as we both, at very different scales, work to reduce health inequalities across Europe.