Time to get tougher on the risk factors fraying our health? – with Professor Kevin Fenton and Richard Sloggett Episode 18 of the Health Foundation podcast

4 April 2022

Time to get tougher on the risk factors fraying our health?

For the last decade, gains in life expectancy have been stalling. We’re living more years in poor health too, with a 20 year gap in healthy life expectancy between women living in the richest and poorest areas. 

The biggest risk factors driving the UK‘s high burden of ill health are smoking, poor diet, physical inactivity and harmful alcohol use. All are socioeconomically patterned and contribute significantly to widening health inequalities. 

There have been many policies proposed to help over the years, and the government has already set a target to increase healthy life expectancy by five years by 2035 and reduce inequality. But at the current rate of progress this will take nearly 200 years, not 12, to reach. 

Is it time to get much tougher on the risk factors? And if so, how? A recent Health Foundation report showed that the government could do a lot more to be effective, but will politics allow national government to do what it takes?

Our Chief Executive Dr Jennifer Dixon is joined by:

  • Professor Kevin Fenton is regional director for London at the Office for Health Improvement and Disparities, having previously held the same position at Public Health England. He has also been elected to be the next President of the UK Faculty of Public Health and is due to take up the position in June 2022. 

  • Richard Sloggett is the founder and director of Future Health. Between 2018 and 2019 he was Special Advisor to the then Secretary of State for Health and Social Care, working on the prevention green paper. 

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Jennifer Dixon: For the last decade, gains in life expectancy have been stalling. We're living more years in poor health too, with a 20 year gap in healthy life expectancy between people living in the richest and poorest areas of the country. The biggest factors driving the high burden of ill health are smoking, poor diet, lack of exercise, and harmful alcohol use. All of these major health risks are preventable and contribute a lot to growing health inequalities. Of course, there have been many policies to help over the years, and the government has already set a target to increase healthy life expectancy by five years by 2035 and reduce inequality. But at the current rate of progress, this will take nearly 200 years, not 12, to reach. Is it time to get much tougher on the risk factors then? And if so, how? A Health Foundation report out in February showed that the government could do a lot more to be effective, but will politics allow national government to do what it takes? Well with me to discuss all this, I have two guests. Professor Kevin Fenton is the regional director of public health for London now based in the Office for Health Improvement and Disparities, or OHID. He's also president elect of the Faculty of Public Health. And Richard Sloggett is the founder of Future Health, a think tank between 2018 and 19, he was special advisor to the then Secretary of State for Health and Social Care, working amongst other things on the last prevention green paper. Welcome both. So I thought maybe the first place to start is to see if you both can just give us a picture of health in the country, the kind of trends and the main risk factors, what's been going on perhaps in the last five years or so?

Kevin Fenton: So I think any reflection on the last five years must take into account the tremendous impact of the COVID-19 pandemic. And as we're still going through it, we're beginning to see some really important patterns and trends, which I think are going to set the scene for what we can expect in the years ahead. So, we're exiting this wave of the pandemic now with demonstrable impacts on increasing health inequalities. A number of our health indicators, whether childhood obesity, increasing alcohol intake, mental health challenges, are all going in the wrong direction as a direct consequence of our experience of going through the pandemic. Now, these effects are on top of much longer term trends that we have been seeing in terms of health in the UK. And yes, we have been seeing improvements in life expectancy, but we know that had been stalling more recently. And certainly with the pandemic, we're likely to see some deterioration in that. We know that we have been experiencing a rising burden of noncommunicable diseases. And again, the direct and indirect impacts of the COVID-19 pandemic may well mean that the challenges of grappling with NCDs will become even more of a priority as we emerge from the pandemic. And clearly I think government is very concerned about inequalities and how these have been widened throughout the course of the pandemic. Certainly, you can look at the differences across the UK in healthy life expectancy, where we see a nearly 20 year difference between the least deprived parts of the country and the most deprived parts of the country. And within regions, we see significant variations in terms of life expectancy, healthy life expectancy, and the prevalence of NCDs and their risk factors. So putting it all together, I think we're at an important point as we deal with health in the UK. We have enormous lessons from the pandemic. We're dealing in real time with the direct and indirect impacts, but this is in the context of wider health challenges and inequalities challenges that we're going to grapple with as well.

Richard Sloggett: I think if you look at the sort of variations in life expectancy, where we were heading before the pandemic arrived, things were heading in the wrong direction. I mean, there was the famous tube map, I think in 2012, which showed that if you start at East London, you go through to the West End it's a 20 year gap on the underground. And then there's the question of what's driving that? And how do you end up tackling it? I mean, take one area, right? Take obesity. If you go back to 1980, obesity rates were in the low single digits for men and women. Now we're in the high 20 per cents and we've got real problems with severe obesity. And Kevin mentioned childhood obesity problems through the pandemic. And again, those were increasing before we entered COVID. Look at smoking rates, again, they've been actually moving in the other direction. They've been on a positive trajectory down from sort of 40 odd per cent down to about 15 per cent from like 70s to today. But we're getting a bit stuck. And again, in the pandemic there's been some evidence of younger people taking up smoking. So the last two and a half years or so have been very, very difficult, but in a number of ways we were off track before COVID, and I think COVID's really sort of highlighted some of the big, big challenges that we now have to kind of grapple with.

Jennifer Dixon: Yeah. And there seems to be a will now doesn't there, the pandemic seems to have unleashed this with the visibility of the way that COVID was just so unequally distributed. Or at least its impact was just so harsh, both the direct and indirect impact. And actually we've known about some of these trends that you both nicely lay out for some time. And we haven't been short of policies. In fact, I was reading a paper that looked at 36 policies in the last 20 years that there's been on trying to improve our health. I wonder whether you were both able to characterise the main thrusts of recent approaches to tackle some of the main risks factors?

Kevin Fenton: So, the past decade, I think we've had a wonderful and maybe a very unusual confluence between government policy focusing on health, National Public Health Agency and Public Health England being able to be in that translational interface between policy and implementation. And the move of public health back into local authorities and the changes within the NHS really providing that focus on prevention. So yes, there've been a number of white papers and policy papers over the past decade. But when you think of the trajectory, what they've been able to do is to guide a system which some may argue is fragmented at risk of even greater fragmentation, to focus on the most important things in terms of preventing non-communicable diseases and diagnosing them earlier, managing them effectively. And then driving towards better outcomes. So we can see in some is where we've seen positive impacts of that. So if we look specifically at the tobacco control plan, so this current plan was developed in 2017, big ambitions towards a smoke-free generation by 2030. Great targets in terms of reducing overall smoking prevalence. Reducing smoking in pregnancy. Really reducing rates of smoking in young people and investing in new technologies, new approaches that guides practice both within local authorities who are commissioning services. The NHS as part of their NHS long term plan and clinical preventive services for tobacco control and also guides the sort of universal policy interventions from government that helps us to have better tobacco control. So whether it's increasing the pricing of cigarettes, looking at advertising, looking at the support for prevention programs nationally, that's the benefit of these policy papers. We could look at the obesity plan again from 2017, where really there is a strong focus on the sugar drinks levy, the industry levy, really looking at reformulation. And of course, thinking about the food environment, both nationally and locally. So these plans, I think have a place to play. I think there's a real danger that we focus too much on policy development and perhaps not so much on implementation and impact. And of course, for all of these policies to work, we need to ensure their resources and the capacity of the staff, especially at a local level to deliver. And I'm hoping that as we move into this new post-pandemic phase of recovery, that some of those lessons on translation and implementation will be core to some of the new initiatives which are being launched.

Jennifer Dixon: Yeah, it's a good point on implementation, isn't it? But the paper I was reading about looking at the policies over the last 20 years or so, they show some repeated messages, which are that the policy has been quite tentative. I mean, you mentioned tobacco, so that's probably the least tentative one. But on obesity particularly, prevention policies have been partial, repetitive, tentative, uneven. And with implementation being spotty, let's put it that way. We see that some of the dials as you started out are moving in the wrong direction. So I'm interested in Richard, your point of view, given the fact you had a hand in the last green paper, what you thought about the last few years of policy?

Richard Sloggett: Yeah. So I think the challenge that you have when you're at the centre is you're trying to sort of work out what the art of the possible is. And public health is very, very political. And if you want to take a wider approach to health, which is generally accepted to be the right way of approaching it, beyond just the health service, then local authorities are a very good place to house public health. However, you can't get away from the fact that we've had a very, very difficult resource framework to operate in over that period. Which has meant the implementation and delivery of some of the national ambitions has been a little bit harder. I mean, one of the interesting things, I think if you look back over last 10 years or so across three different prime ministers now is all of them have come to government with a degree of scepticism about acting on elements of public health. So if you take the Cameron government, the May government and the Johnson government, all three starts off, if you take something like obesity as being fairly sceptical about the role of the state and the role of government in tackling that. And all of them have to some extent change their view. So, think about the 2012 obesity plan and then the sugar drinks levy that David Cameron brought in the sort of 2012. Theresa May, her advisors gutted the obesity plan. And then they started to get very much into it after a couple years and Boris Johnson's gone through his own kind of scepticism of elements of that. So I think when you're sitting in government, you are trying to sort of balance the kind of different interests and the different views and trying to work out what the art of the possible is with regards to public health policy. And that is not an easy thing. So when it comes to prevention green paper, for example, we were constantly trying to work out how far can we realistically go, given the political mandate that we had? And the political mandate, frankly, when I was in government was very limited. We were dealing with the Brexit challenges, of course, in particular. So moving the needle on public health policy at the national level involves a number of different interests and trying to manage some of those political issues, which is not easy or straightforward.

Kevin Fenton: And if I could just come in here. There's also the other aspect of this, which is the systems and the structures are evolving and changing over time. So, in the last decade we've had the creation of a new National Public Health Agency in the last year that's been disbanded. We now have two public health agencies, one leading on health protection, another on health improvement and disparities. We're seeing changes in the NHS. So those structural changes, the leadership change, the changing staffing relationships also means that we do need to refresh a lot of our strategies because it has to take into consideration the new governance, context structures, funding relationships, because of the structural changes, which are occurring as well. So we're dealing with changing epidemiology and burden, but the system itself continues to evolve. And I think there's something for us to learn, not only about the policy translation implementation and scale a pathway, but how we become much more agile in understanding how these structural changes are influencing our progress as well.

Richard Sloggett: And could I just add on that?

Jennifer Dixon: Yeah.

Richard Sloggett: Because I think it's an excellent point. The King's Fund paper that's come out just recently from David Buck and David Lewis is very good on that.

Jennifer Dixon: Yes.

Richard Sloggett: Because it basically says in order to make public health stick, you've got to have the action coordinated across those different levels, national, regional, and local. And too often, we all either relied on, say a national top down model or we've delegated it too much. And I think actually the new structures do give us an opportunity to kind of coordinate action in a more coordinated way than maybe in the past.

Jennifer Dixon: Just pinning you a bit to the wall a bit there, Richard, on national policy. I mean the room for manoeuvre you say is limited sometimes, it's politically constrained. Governments have been very muscular on smoking, but they have been uneven on alcohol or at least more reluctant on alcohol. They've been much more reluctant on obesity. It's really quite tentative what's happening. And you can see that because you can see what the stats show us about obesity. So why are they more reluctant on alcohol or obesity, more generally? Is this something to do with ideology or is it something to do with commercial influence, do you think?

Richard Sloggett: So? I think it's probably a bit of, I mean, alcohol, we haven't spoken about alcohol and, I mean, the trends, there are very worrying with the rise in alcohol related deaths in the last sort of couple of years in particular. But I think it's both ideology and commercial interests. I don't expect, and I don't think Kevin's going to give us any previews on, what's going to be in the health disparities white paper today, but I wouldn't expect huge amounts of action on alcohol because politically I think it is frankly, just too difficult. I think if you look at what's happened to the beer and pub trade in the last again, two years, that's been very, very hard. I think any additional moves on alcohol or pricing or whatever it is I think would be met with severe political resistance. On obesity, as I said, previous, I think what happens on obesity policy is that prime ministers go through a sort of journey. Conservative prime ministers anyway, where they think, 'No, we're not going to take any significant action. We're going to make this more about individual agency'. And then actually over time, they realise that the numbers are going in the wrong direction and they need to be more muscular and more interventionist. But then there again is strong pushback from commercial interests. And I think if you look at what's happened in recent years, actually the policy frameworks have been pretty bold. If you look at internationally, we actually are doing quite a bit where we're committing to doing quite a lot of things in relation to tackling obesity. But they don't happen particularly quickly because they get slowed down by some of those interest groups who sort of push back quite hard against them and talk about the cost and the economy and everything else. And there is a group of parliamentarians who are very vocal on those sorts of issues. On smoking, I think for a long, long time, there's been a big coalition against big tobacco that's been built over many, many years and big progress has been made. There are there lots of alternatives now that have come through to getting people off cigarettes and away from smoking. So I think that agenda's been a huge success, but I would agree with you on the other two big drivers. On obesity, there's been some progress, but it's too slow. And on alcohol, we are very much in the starting gates.

Jennifer Dixon: Yes. I mean just on alcohol, obviously Scotland and Wales, I think people know about the policy there that was introduced in Scotland 2018, where they introduced minimum price, 50p per units of alcohol and Wales followed suit a couple of years later. And the results included alcohol sales in Scotland falling by 8% after the policy was introduced. Mostly in households that bought the most alcohol, which was quite interesting. So you think those sorts of figures scare the commercial lobby in England, but yet it doesn't seem to have deterred the Scottish government.

Richard Sloggett: Yeah. I think for the UK government taking additional action on alcohol, just particularly at the moment, I think would just be very, very difficult. And indeed when I was in government, when looking at the prevention green paper, if you looked at the alcohol section of that document, it's very, very light touch. It doesn't commit to anything. I think there was a study on that we'd committed to look at minimum unit pricing, but there was no strong commitment in there. And I wouldn't expect there to be, as I say, huge amounts of new work being or new commitments coming through on that. And devolve governments, obviously public health has devolved. They're able to make their own decisions and their own judgements. But I think you would find such a strong backlash on that politically. And again, the government's political position has changed. So when this government was elected, had an 80 seat majority, it was a pre COVID world. We were pre-party gate. We are now a different political dynamic. What is the art of the possible on public health policy in this political climate two years out, potentially from a general election? I think the dynamics have changed and I would strongly expect to see lots more action on smoking with the 2030 commitment as Kevin says and on obesity where policies just need to be taken from white papers and put into practice. On alcohol, I think it is just going to be a bit more difficult.

Kevin Fenton: And Richard, I think there's also another dimension here, which is what may be less palatable nationally may find more traction locally and in place. And there's also the thinking about what are the effective tools that we have in the toolkits that are not yet implemented consistently and at scale to have at least some impact. So, what more can we do for example, with brief alcohol interventions in the NHS? What more can we do to support referral services? What more can we do to encourage alcohol as a consideration for local licensing? There are things that at perhaps at the local level and by empowering local action and looking at and supporting innovation in the meantime, while we're waiting on some of the bigger policy lifts like MUP may well be the strategy that we'll have certainly here in England. And I'm also mindful that as we move forward, when you look at some of the health improvement areas where we've made great progress. Tobacco, and I put into that HIV, you see the powerful presence and contribution of effective advocacy, community mobilization, great science and evidence that guides actions and specific asks of policy makers of clinicians and communities that come together to help to drive some of the change. And I would question whether we have that same sort of alignment of the players for some of the other health improvement areas. And perhaps a question for us is how do we build those coalitions in the years ahead as we merge from the pandemic so that we learn from the successes in HIV, and in tobacco, and apply them to other health improvement areas as well? So agree with you on the importance of national leadership, but there's also an opportunity here for place and coalitions, I think.

Jennifer Dixon: Yeah. So a good example, I think of this is thinking about obesity. And I was looking at some figures from Denmark, which looked at the saturated fat tax that they introduced in 2016 or just before then it improved live saved, 123 in Denmark per year they calculated. So clearly we haven't got that yet, have we? But in London, you've been much more energetic in banning junk food advertising, for example, on transport for London, which has had an impact, hasn't it, Kevin?

Kevin Fenton: It has, and this is a another great example where place and looking at the innovation and the ways of working in place can be a huge addition to our efforts nationally to address some of these issues. So in London, as we are emerging from the pandemic and we are now articulating our recovery missions, which are cross-cutting regional ambitions for the city where we're bringing together partners from business, from academia, from the community, from health and care together to focus on some of big issues for the city. So whether it's the environment, whether it's economic recovery, whether it's giving every child the best start in life, straight through to healthy weight and mental health. It's galvanising Londoners and London leaders around these big changes that we'd like to see. And in London, in addition to the ban on advertising, we've been able to work at the regional level with our local partners on innovations, such as school super zones, for example, promoting water only policies in our schools, in the city. Really focusing on issues such as healthy high streets and how we integrate better food offerings and the food environment in the high street. Working with caterers around healthy catering and making commitments around healthy catering, as well as focusing on issues such as breastfeeding at the regional level. So, we do have opportunities here to perhaps go a little bit further than national government is doing, to pilot some of the innovation and then work at scale in place as part of what I think we need to be doing to tackle some of these issues.

Jennifer Dixon: That's great. And we'll come back to the local in a minute, actually. I just want to, sorry, one more time to press Richard. Governments, obviously, as you say, have a restricted room for manoeuvre. They have all sorts of special interests and commercial interests to consider as well, as well as their own sort of ideology about the role of the state versus the role of the individual. But meantime, these dials are getting worse and it's costing. It's costing the NHS it's costing business. We saw, obviously the number of economically inactive people now out of the workforce cause of chronic ill health, a lot to do with obesity. And people in work, taking time off for increasing chronic disease. What does it take for more action to be forthcoming at national level? Can the government just sit on its hands here in the way that it has done forever?

Richard Sloggett: Oh, I think this is a great question, Jennifer, because I think for the conservative part, this is where they find themselves in a real bind. If you look at Sajid Javid's health reform speech, at the Royal College of Physicians, he made a big play on prevention, which is music to my ears because it was something that was raised front of mind for my former boss as well. And he was coming at prevention from the kind of cost implications for the health system of us, not catching diseases earlier. But then that runs very much up against the individual agency points about what is the role of the state? And where should the state intervene and where should it leave it to the individual? And it was very interesting speech because basically his argument was we are raising more taxes to pay for the NHS. There's lots of public support for that. And that's going to go through in April. But there is going to be no additional money. We now need to make that money that we're spending work more effectively and divert resources over time towards more primary care prevention, et cetera. But there's no evidence internationally that you can make that shift in health systems from investing in and treating disease to preventing it and bringing down the overall health system budget. And none that I'm aware of, I'm happy to stand corrected on that. And I think this is a really interesting challenge for a conservative party and the health service. And over the last 10 or so years since, since Tories have been in government, I think that the approach has been, we'll just top the HS up with just enough money just to keep things moving. And the speech last week said that we now have gotten to a point where we are not going to be able to keep doing that. We're going to have to try and redesign services, but given everything that we've seen through COVID-19, given all the stresses and strains and pressures in the system, can you do a redesign like that in this particular environment? As Kevin says, the structures are all changing positively, but that takes up a lot of time and resources. And this is why I think it's really interesting because you could make strong economic arguments about the need to invest in preventative services because they save money down the stream and over time. But then you run into our friends at number 11 in the treasury who don't necessarily see the world in that investor save model. So it's a fascinating political challenge that you face where you would, if you were spending money, you want to spend more money on the public health related interventions because you get the better return than you do from the NHS. But the public wants more money in the health service rather than in the wider determinants. So that's the political issues that you are juggling.

Jennifer Dixon: Yes. And it may be cheap for you to start talking about minimum unit pricing of alcohol or some other tax that might, a syntax as they used to be called. I mean, I'm just wondering whether they will be pushed towards that as time goes on? Because the sugar tax, as Kevin said has been incredibly successful, hasn't it? So, I'm just interested why there is more reluctance to go further down that track?

Richard Sloggett: I don't think we should underestimate how big a deal it was that they broke the tax lock in their manifesto to fund that. So that is a huge deal for a conservative party to break a tax pledge, to fund the NHS. I mean that is highly unusual. And I think the secretary of state speech basically said, 'This is highly unusual. Now we need to make sure we're getting value money and we're investing in new and innovative ways. And we do need to try and get on top of some of those prevention base'. I mean, there's really interesting things going on in the NHS. Particularly if you look at things like diagnostics and community service, community diagnostic hubs, and those sorts of things. And the role of data digital in some of that. But I think it's just politically. And this, is where I think the health disparities white paper's going to be quite interesting to see how it lands. Because if you want to make a big play for prevention, and if you look at the levelling up white paper, for example, the five healthy life years that we were supposedly delivering on 2035, I mean, what levers are we going to be pulling to get there? I mean, we're so far off track from delivering it. You'd have to see such a huge uptick in interventions and investment. Kevin at the start mention resourcing. It's so important. Where's like going to come from? And how is it going to work? And there's a big opportunity to make some big changes. There's a lot of faith being placed in that health disparities white paper, I think which, which is why I think there's so much writing on it.

Jennifer Dixon: If national government has limited room for action for ideological reasons or even economic reasons, what, Kevin, than you were saying earlier about really sweating the assets locally is going to become critically important, isn't it? As you say, you mentioned some of the partners there including business, and I think that's quite an interesting link, isn't it? I've just joined the CBI's health council and they are wanting to do a lot more to improve health. What other sort of assets do you see locally to try to help if public health departments are starved of cash? And local government is indeed. Where are the new assets that we can pull on under the next couple of challenging years, at least?

Kevin Fenton: Well, I just want to echo what Richard has said about the difficulties that we may be facing from sources and policy. But I think we also need to take account of some of the opportunities as well. And from where I sit as regional director for London, I'm looking both to national colleagues and seeing the changes and beginning to ask, 'How can we leverage them for impact?' But also looking locally as well in terms of, 'How do we implement the lessons and the legacies of the pandemic to do things differently and to behave differently as leaders and to work differently with our communities?' So just in terms of the national opportunities that we have, despite the challenge that Richard so clearly outlined, we do now have a new agency, the Office of Health Improvement and Disparities. Which in my 30 plus years of practicing public health in the UK, this is the first time we have an office that has disparity in the title. We have a health disparities white paper coming out, which is again, the first time in my career where we're going to have this laser like focus on health disparities. And yes, we may argue disparities inequalities, but most important is that we're beginning to focus on what has been so apparent in the pandemic. You now have the NHS changing and the ICS is being established and prevention being hardwired in that work, as well as tackling inequalities. The Health Promotion Task Force that is now working across government, bringing different government departments together, to focus on big issues in support of health improvement and health disparities, is another important structural intervention nationally that I think we need to take full advantage of. So not to minimise the challenges, but recognize that this is a dynamic system and things are changing. And then finally, just to reflect on some of the local opportunities. There are very few silver linings of going through a pandemic of the scale and impact that we've just been through, Jennifer. But one thing I can honestly say is that it's built new partnerships. We've brought new partners to the table. We have deeper engagement with our communities. We have conversations now with businesses, academia, with the faith institutions, et cetera, which perhaps we never had as richly and robustly for. And the key opportunity for us is how we then convert these new relationships that have been forged through COVID into meaningful action. We need to use these new partners, new ways of thinking as we move ahead.

Jennifer Dixon: Yeah, that's very hopeful actually. And a couple of podcasts ago, actually, we had a really interesting discussion between Share Action and a big investor, Legal and General, about how investors actually are using what's called ESG Environmental and Social Governance mechanisms to try to prompt businesses or people invested in, into becoming healthier. Just like the green agenda effectively has started this for green and carbon, to do that for health. And there's quite a lot of action there too, as well as the CBI I mentioned earlier. So, it seems as if we kind of look upwards don't we to international go a lot. But as you say, locally, as well as with investors and business, there is also more action with a range of players. But scale of it is just huge, isn't it? Who's keeping track of the dials? Who's then monitoring how efficacious these policies are? Presumably that's something that OHID will be doing, Kevin?

Kevin Fenton: I think so. OHID will certainly be able to carve a space out in that. I mean, we're already looking at the public health grant and how the public health grant is spent. But as I have repeatedly said, the public health grant is perhaps a small part of the complete investment in prevention that we have in a locality or in place. And what we need to get better at is being able to quantify the spend from the NHS, from social care, from public health, and wider local government into prevention, and to understand how that's evolving over time. And to ask questions about, are we investing in the right things and are we doing so at scale? And I think that ICS is. By really taking a population health management approach to big health issues, we'll be able to look at the pathway from prevention, early diagnosis, care to rehabilitation and ask questions as to whether that we are investing in the right way in the pathway for improving health. And whether we need to shift where resources are locally. I firmly believe that if we're going to make gains, it has to be by empowering place. We need strategies which are developed with communities which are meaningful and able to evaluate our impact and resourced. And we need to use the new structures that we have to maximum effect. And I think place is really where the energy needs to be now moving forward.

Jennifer Dixon: I always ask guests about their final thoughts for hope, where we can make most progress. What would you like to see maybe in the next couple of years on this agenda, given that it's so massive?

Richard Sloggett: Yeah. I think there are some political challenges in striving some of this forward. But, as Kevin says, I think some really, really good opportunities and actually knitting the system together much more tightly. So if you look at the top of government, you've got that health promotion task force, that's chaired by the prime minister that Kevin mentioned. You've got the new office for health improvement disparities, which has a real clear line into ministers with clearer ministerial accountability. You've got a white paper coming through links to wider government policy in terms of levelling up the creation of ICS as the core 20 plus five program within the NHS. And then you've got your place based approaches and your community engagement and community outreach. And we've learned, I think, as a system, a lot in the last two years through the pandemic. If we look at the success of the vaccination program. Look at all of the work that's been done to engage with as many different people and many different communities as possible to try and drive those vaccination rates up. There's a huge amount of knowledge and learning and the system change that's happened. It would be a really, really positive, a huge success story. I think if we could take some of that can-do spirit and that kind of joint working and that collaboration forward, I think there's a lot that could be done in the next couple of years, even though some of the politics and some of the public health community would likely be a little bit disappointed that there won't be some action in some certain areas. There's also Jennifer, some really good commitments that we've already got 2030, 5% of the population smoking, childhood obesity positive. If we could drive some of the implementation of that quickly, a positive COVID legacy stuff. So a better system and some real drive on some of the implementation of some of the commitments, I think would both be positive things to see in the next couple of years.

Jennifer Dixon: And just while I've got you on the spot, I'll ask Kevin this as well. Are there really interesting international examples? Is anyone getting this right as far as you can see?

Richard Sloggett: Well, the model I was quite taken by. And we committed to the develop the ONS Health Index in the prevention green paper where it was Sally Davies' piece. I think the measurement of health is something that I think we can take some pride in here with that index and moving that forward. I think if you look at New Zealand and I think Wales has now got this kind of, "We want to measure wellbeing. We want to line it up with GDP. We want to have a broader conversation about what we're investing in, who we are as a nation, et cetera." I think that agenda's quite interesting because it gives you a kind of a place to point your public health policy. It's, "Why are we doing this? Why are we having these discussions about these particular interventions?" Why actually we want people to live happier, healthier lives. And target of five of your life years is great, but actually how do we measure that? How do we track that? How do we engage with different communities? And I think that's a really interesting kind of piece, which I think we've started the work on. And I think there's a lot more that could be done. And if you're looking at ICS's coming up with implementation frameworks and outcome frameworks that sit across public health NHS and care. We need to be measuring those sorts of things closely and engaging with the public on it. So, that's just one bit, I think internationally, which I think is quite interesting that we could probably learn something from.

Jennifer Dixon: And Kevin, what would you like to see over the next two to three years?

Kevin Fenton: We are still living with COVID and there's a lot of talk now about what are the lessons from the pandemic. And I really want to switch the narrative to talking about the legacies of the pandemic. And over the next two to three years, I'd love to see us literally hard wire in the sort of lessons that we've learned into meaningful behaviour change from leaders, governance, the way we structure ourselves, the way we operate, and how we actually deliver services to drive impact. And even in London, as we're sort of taking stock of what we need to do and the legacies, I think there's some clear areas where we now want to do things better. And this includes, first of all, the way in which we've learned to work between public health, health, and social care, integrating our services and keeping that focus on equity. We really want to use the ICS development as another step in that integration. The way we've learned to work in partnership to pool budgets, to think about distributed leadership, to really bring communities at the centre of policy making, not just for COVID and vaccine equity, but for mental health and other issues. We want to take that forward, lock that in and turbocharge that moving forward. The data Jennifer, that we've had to understand the epidemiology, to target or interventions and to really push COVID prevention and control, sets a bar for the sort of data I'd like to see moving forward. And to work with population health management systems with public health, to really ensure that we're now being smarter in the data that we're collecting and the insights that we're having in order to drive efforts. And our academic colleagues have a key role to play in ensuring that research that we commission is program relevant and is focused on tackling inequalities. And then finally, over the next two years, I really want us to hard wire in as a legacy, what we've done on community based and asset based approaches to health. That must be part of our legacy of the pandemic. And we have great examples with the vaccine program that we should be building upon for every health improvement priority moving forward.

Jennifer Dixon: So thank you to my two guests, Kevin Fenton, and Richard Sloggett. The show notes for this podcast episode, check them out. They include reference to the recent Health Foundation report on risk factors and what the government should be doing next. That's worth a read. And next month, given that we now have the highest inflation rates in 30 years leading to large cuts and real incomes and living standards, we explore the issue of how this is affecting our health and what to do about it. Meantime, thank you for listening and see you next time.

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