BHF Response to Public Health White Paper - British Heart ...

Healthy Lives, Healthy People
Response from the British Heart Foundation
Summary
The BHF welcomes the Government’s focus on public health and the commitment to
adopting a cross-government, life-course approach. We look forward to learning more
about the mechanisms that will be in place to support this and to ensure integrated action
to address the wider determinants of health
History shows that public health benefits and reductions in health inequalities most
frequently result from timely, evidence-based legislation. To protect population health,
particularly children and young people, and to create an environment that supports and
enables healthy choices, individual behaviour change approaches and voluntary action by
industry must be part of a much wider government strategy that includes regulation and
legislation
In particular, legislation and regulation are needed to protect children from the marketing
of food and drink that are high in fat, salt and sugar (HFSS) and to introduce plain
packaging for cigarettes
While we support local community empowerment, there must be national oversight to
monitor outcomes, including among black and minority ethnic, geographical, and other
population groups
The transition period must be carefully managed, to ensure that specialist public health
expertise and experience is not lost
The Public Health Service, including Public Health England and Directors of Public Health
(DsPH), should have the protected independence to advocate and influence in the
interests of population health
Public health practice must be based on evidence and robust evaluation. Local Information
officers, information systems, and the development of effective links between
commissioners, providers and academia will be needed to support this
Open and transparent access to independent reliable national and local data on population
health needs and outcomes, including the Public Health Outcomes Framework, will be an
important mechanism for enabling genuine scrutiny and accountability
The voluntary sector, patients, the public and academic institutions should be fully
engaged and involved throughout the commissioning cycle
General comments
The British Heart Foundation (BHF) is the UK’s leading heart charity. Our vision is of a world
where no-one dies prematurely of heart disease. Heart and circulatory disease is the UK’s
single biggest killer, and costs the UK £30.7billion each year 1 . Despite recent improvements,
death rates from cardiovascular disease (CVD) in the UK are relatively high compared to other
1 NICE (2010). Prevention of cardiovascular disease at population level
1 Submitted 31 March 2011

developed countries, and there is also considerable variation within the UK - geographically,
ethnically and socially 2 .
In more than 90% of cases, the risk of a first heart attack is related to potentially modifiable
risk factors, including smoking, poor diet, obesity/overweight, and insufficient physical activity 3 .
We are pleased to see this Government focusing on public health.
While we welcome the commitment to a ring-fenced budget, the scope of this budget needs
clarification. The actual amount allocated to local authorities must be sufficient to enable
DsPH to drive health improvement, and activities must not be re-badged as ‘public health’.
A cross-Government approach
There is a strong relationship between coronary heart disease (CHD) mortality rates and
levels of deprivation. People from particular ethnic groups also suffer disproportionately from
cardiovascular disease 4 and a number of related risk factors; some but not all of this variation
relates to deprivation.
Measures to prevent heart disease and other non-communicable disease at a population level
have co-benefits for a wide range of policy areas, including sustainable development, climate
change, and poverty reduction.
We welcome the commitment to addressing the ‘root causes of poor health and wellbeing’ and
to adopting a cross-Government approach. We look forward to learning more about the
mechanisms that will be in place to achieve this and enable Public Health England to
work closely with other Government departments. Health Impact Assessments and Health
Equity Impact Assessments should play a key role in cross-Government working.
We support the commitment to improving the health of the poorest, fastest. To reduce the
social gradient in health, actions must be universal, but with a scale and intensity that is
proportionate to the level of disadvantage 5 . Greater consideration should be given to tackling
health inequalities by ensuring a healthy standard of living for all.
A life-course approach
We support the Government’s commitment to adopting a life-course approach to public health.
The Marmot Review clearly shows the effect of the early years (both pre-natally and preschool)
on lifelong health and wellbeing, including heart disease and obesity 6 .
A key aspect of this should be the promotion of healthy eating and physical activity
from a young age. This is particularly important among high risk groups (for example the
Marmot Review shows how obesity varies among different ethnic groups, and anticipates an
increase in obesity among lower socio-economic groups) 7 .
Daycare providers have a vital role in this, particularly as the number of under-5s in daycare
and the length of time spent in daycare is increasing 8 . In our recent response to the Review of
the Early Years Foundation Stage, we called for greater emphasis and specific learning goals
on nutrition and healthy eating. The Framework should also incorporate the forthcoming
guidelines around physical activity for the under-5s and details on what providers can do to
2 British Heart Foundation Health promotion Research Group (2010). Coronary Heart Disease Statistics 2010
3 NICE (2010). Prevention of cardiovascular disease at population level
4 The rate of CHD is one-third higher among men in the most deprived group compared with the least. The difference is even
greater in women – those in the most deprived group have a rate of heart disease at least 50% greater than the least deprived
group. South Asians living in the UK have a 50% greater risk of dying prematurely from CHD than the general population
(www.heartstats.org.uk)
5 Professor Sir Michael Marmot (2010). Fair Society, Healthy Lives
6 Ibid
7 Ibid
8 The Caroline Walker Trust (2006), Eating well for under-5s in childcare
2 Submitted 31 March 2011

contribute to these, as well as providing greater clarity about what constitutes a ‘healthy,
balanced and nutritious’ diet.
Regular training is crucial to equip staff with the skills and knowledge to plan menus and
prepare meals that meet nutritional requirements and to facilitate appropriate physical activity
for this age group. Parents should also receive information about healthy eating and physical
activity – the stage at which children start school is a prime opportunity for this. We welcome
the commitment to increased numbers of health visitors.
The White Paper gives helpful indications of what ‘good schools’ will do to promote health, but
monitoring must be in place to identify schools that are not meeting expectations and these
should be offered high quality, evidence-based support and guidance. We welcome the
commitment to supporting walking and cycling in schools, but we are concerned about the
apparent focus on competition in sports and believe this may not be the best way to engage
the least active.
We understand that there will cease to be a nationally recognised Healthy School Status and
urge the Government to ensure that the necessary infrastructure and support is made
available so schools can protect the health of children and young people. While food provided
in schools will continue to be regulated by legislation, schools must be motivated to take
broader action, including promoting healthy packed-lunches and healthy food purchased
outside the school gates. We would welcome clarification about which body will have
responsibility for monitoring performance against existing school food standards.
The Ladder of Interventions and the place for regulation
The Government’s role in ensuring robust national, independent and transparent timelimited
monitoring of progress against Responsibility Deal pledges will be crucial.
We firmly believe that complementary measures from different ‘rungs’ of the Ladder of
Intervention 9 are needed – rather than starting with the least intrusive measures and
progressing incrementally up the Ladder.
The provision of information, behaviour change (‘nudging’), and voluntary action by industry
will not on their own deliver the health outcomes to which we are all committed. Many aspects
of the environment set the default options for behaviour and decision-making. The physical
environment and commercial marketing, for example, can make positive health behaviours
and healthy choices more difficult. In addition, while we recognise the importance of personal
freedom and responsibility, this must be balanced with the need to protect population health,
particularly among vulnerable groups including children who cannot be expected to take
responsibility for their decisions.
History shows that public health benefits and reductions in health inequalities 10 most
frequently result from timely, evidence-based legislation. This is shown, for example, by
the seat belts legislation and the recent Review 11 of smokefree laws. We also believe that
upstream whole system measures are the most cost-effective 12 .
We were pleased to see the Tobacco Control Plan commit to the implementation of the
legislation to prohibit the display of tobacco, and to consulting on plain packaging for
cigarettes. Despite health warnings, packaging remains a ‘silent salesman’ for tobacco
brands. We firmly believe that to increase the effectiveness of health warnings and
9 Nuffield Council on Bioethics (2007). Public health: ethnics issues
10 www.scotland.gov.uk/Publications/2008/06/09160103/2
11 University of Bath (2011). The impact of smokefree legislation in England: Evidence Review
12 For more information, please see the evidence-based cost-effective upstream measures recommended in NICE (2010).
Prevention of cardiovascular disease at population level
3 Submitted 31 March 2011

address misconceptions about the risks of smoking, legislation is needed to introduce
plain packaging for cigarettes across the UK.
Legislation and regulation is also needed to protect children and young people from the harm
caused by the marketing of food and drink that is high in fat, salt, and sugar (HFSS food and
drink). Although the advertising of HFSS foods and drinks is prohibited during children’s
programming, a recent review by Ofcom 13 showed that just over half of children’s viewing time
is in commercial adult airtime (when programmes such as X factor, and Britain’s Got Talent
are shown). A complete ban on HFSS advertising and product placement before 9pm
would offer better protection from slick marketing campaigns, and legislation and
independent regulation should also be applied to non-broadcast media - the internet, in
print, and on food packaging.
The role of the centre
The ambition to keep ‘to a minimum constraints as to how local government decides to fulfil its
public health role’ will need to be carefully balanced with the requirement to deliver evidencebased
and equitable interventions and outcomes. The action taken by local authorities will
inevitably vary, and the Government will need to monitor outcomes among geographical,
black and minority ethnic, and other population groups, and take responsibility for
ensuring that action is taken where unacceptable variation in outcome persists. We
would welcome more information about the process for making sure that this happens.
The Public Health Service, including Public Health England and DsPH (see below) should
have the protected independence to advocate and influence national and local government
and the NHS. We have concerns about how Public Health England will achieve this level
of independence if it is a fully-integrated part of the Department of Health.
The provision of public health guidance and national minimum standards (such as the
school food standards) to support local decision-making will be crucial. We welcome
the commitment to providing local areas with evidence on how ‘to make regular physical
activity and healthy food choices easier for their populations’.
DsPH should work to implement NICE public health guidance, including guidance on the
prevention of cardiovascular disease 14 , prevention of overweight and obesity 15 , and on
physical activity and the environment 16 . We would like more information on which bodies will
pick up those pieces of guidance that have been removed from the NICE work programme,
including aspects of tobacco guidance and spatial planning for health. NICE should also
review upstream national and international public health measures (it should not just focus on
local interventions).
The new responsibilities of local authorities and DsPH
We welcome the transfer of local public health leadership to local government. However, the
transition period must be carefully managed to ensure that current specialist public
health expertise and experience is not lost. The forthcoming Public Health Workforce
Strategy should give careful consideration to ensuring a coordinated approach to workforce
training and supply, and should consider not just DsPH but those who work in jobs that have a
bearing on health (such as planning and transport).
DsPH are exciting roles with great potential to tackle the wide range of social determinants of
health and health inequalities. To achieve this however, they must have the protected
independence, authority and resources to advocate and influence all policy areas that
13 Ofcom (2010). HFSS advertising restrictions - Final review
14 NICE (2010). Prevention of cardiovascular disease at population level
15 NICE (2006). Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in
adults and children
16 NICE (2008). Promoting and creating built or natural environments that encourage and support physical activity
4 Submitted 31 March 2011

have a bearing on health and health inequalities. Committed, strong and stable leadership
will be needed to develop new working cultures.
The Health and Social Care Bill must therefore require DsPH to have Executive Director
status (second tier officers), reporting directly to the Chief Executive in the Local Authority.
The Bill should also set out the statutory roles of DsPH including being a formal consultee,
advocate and advisor on all policy areas and functions that have a bearing on health (such as
planning, education and transport).
Forthcoming Public Health Plans
We recognise that the Public Health White Paper provides the overall public health framework
and that more detail in particular policy areas will be provided in associated Public Health
plans.
Social marketing
Population-level information is crucial to support people in making healthy choices. We look
forward to reading more in the forthcoming Social Marketing Plan about how healthy diets,
physical activity, smoking cessation and smoke-free homes and cars will be promoted through
the forthcoming Social Marketing Plan.
The Plan must give particular consideration to the need for dedicated interventions and
awareness campaigns for disadvantaged groups that suffer disproportionately from
cardiovascular disease, including some black and minority ethnic groups.
Obesity and Physical Activity
We would have liked to see greater reference in the White Paper to measures to promote
healthy diets and hope to see more detail in the forthcoming Obesity Plan. In particular we
would like to see proposals for legislation and regulation to protect children from junk food
marketing. We also look forward to learning more about the Government’s plans to promote
physical activity and active travel in the Physical Activity Plan.
We strongly agree that active travel and physical activity need to become the norm in
communities and welcome the recognition that ‘improving the environment in which people
live can make healthy lifestyles easier.’ Access to local parks and safe outside space and a
reduction in the speed limit to 20 miles per hour in residential areas are key to enabling people
to build physical activity into their daily lives. We support Sustrans’ call for public health
objectives to be reflected in the Department for Transport’s Local Sustainable Transport Fund
bid selection criteria.
Information about the nutritional content of food is also crucial to create an environment that
enables consumers to make healthy choices. Research has shown that front of pack (FOP)
labels including traffic light colours, the words ‘high’, ‘medium’ and ‘low’, and percentage
guideline daily amounts help consumers tell at-a-glance what’s in the food they’re buying 17 .
Traffic light labels can also help drive product reformulation, which is an important way of
reducing levels of saturated fat, salt and sugar consumption.
Developments concerning food labelling legislation at European Union level mean that
additional voluntary labelling schemes are likely to go ahead, and it is important that the UK
Government supports this to allow the continuation of FOP labels in the UK. It is proposed that
additional voluntary schemes will give member states the opportunity to endorse a particular
labelling scheme. The UK Government should therefore strongly support and encourage
the use of the Food Standards Agency’s Multiple Traffic Light FOP labelling system, to
help consumers get the most out of FOP labels. Those companies choosing to use their
own labelling schemes must provide independent and transparent evidence to demonstrate
that these are effective.
17 http://www.food.gov.uk/news/newsarchive/2009/may/pmp
5 Submitted 31 March 2011

We are pleased that work is underway on the provision of nutritional information at the point
where decisions are made in cafes and restaurants, and hope to see this extended to give
consumers more comprehensive information about the nutritional content of foods
rather than just the energy content. This is particularly crucial given that one in six meals
are now eaten outside the home 18 .
To eliminate industrial trans fats, action will be needed across small and medium-sized
catering businesses, as well as large suppliers, manufacturers and providers. If voluntary
action is unsuccessful, the Government must take legislative action to remove trans
fats. Additional work is also urgently needed to substantially reduce saturated fat
consumption.
We understand that the Responsibility Deal targets for salt reduction are equivalent to the FSA
2012 targets. However, further ongoing action by manufacturers, retailers and caterers
will be essential to reduce salt consumption to recommended levels.
The crucial role of the NHS in public health
The role of the NHS in both primary and secondary prevention must continue to be
recognised, and NHS health professionals must see this as part of their role and responsibility.
We are pleased that the NHS Commissioning Board will retain a public health role, and
welcome the recognition of the need for close working with Public Health England.
Health and Wellbeing Boards will play an important role in facilitating collaboration between
DsPH and GP commissioning consortia.
All NHS services should work to tackle health inequalities by promoting equitable access to
services (for example, ensuring these are culturally appropriate).
Promoting advanced care planning
We welcome the recognition of the affect of end of life care on the physical and psychological
health of family and carers.
Many people with heart failure want to die in their own home, but most die in hospital 19 .
Having a conversation about end of life care is crucial to meeting patients’ needs and wishes,
yet in many cases, these conversations do not happen 20 . Advanced care planning is a process
through which a person can express preferences for future care, in discussion with their
family, main carer, and professionals. This might include, for example, explaining where they
want to be cared for, who they want to act on their behalf if the person is unable to make their
own decisions, and how they want their religious or spiritual beliefs or cultural preferences to
be reflected in their care. Training for healthcare professionals on how to discuss end of life
care is crucial.
Clinical and social care needs assessments should be conducted with every person
approaching the end of their life, and a key worker should manage any changes in condition.
Patients should be supported by a care co-ordinator to organise and streamline appointments
and follow up requests for equipment (this could be the same person or could be someone
non-clinical, such as an informal carer). 24/7 access to nursing, pain relief and specialist
advice is also crucial to meeting patients’ wishes for end of life care.
Screening for heart conditions
18 Defra (2008). Family Food Survey
19 British Heart Foundation (2010). Better Together, An end of life initiative for patients with heart failure and their families,
Executive Summary
20 For more information please see: www.dyingmatters.org
6 Submitted 31 March 2011

Throughout the White Paper and associated consultations, there is a notable absence of
reference to congenital heart disease, despite this being the most commonly occurring
major congenital abnormality affecting one in every 145 babies 21 . Effective routine screening
ante-natally and post-partum is crucial, and audit and specialist professional training are
needed to support this.
There is also a lack of reference to inherited cardiac conditions. Familial
hypercholesterolaemia (FH) is an inherited condition which causes high blood cholesterol
levels and a greatly heightened risk of heart disease. If FH is identified and treated early, life
expectancy can be normal, but if left untreated roughly half of men will develop heart disease
by 55 and around a third of women by the age of 60. Currently there are around 100,000
undiagnosed people in the UK at risk of heart disease due to FH 22 . NICE has recommended
the implementation of cascade screening whereby first degree relatives of known FH sufferers
are screened for the genetic defect and managed appropriately if found to be affected. Other
inherited cardiac conditions include inherited cardiac arrhythmias, cardiomyopathies, muscular
dystrophies, and other connective tissue disorders, such as marfan’s syndrone.
We understand that screening is to be commissioned by the NHS Commissioning Board,
while the birth anomaly register will be organised and maintained by local authorities and
Public Health England. We support the recommendation of the Genetic Alliance for the
commissioning of screening and the maintenance of the register to be more closely aligned.
The BHF welcomes the ongoing national roll-out of NHS abdominal aortic aneurysm
screening, and the commitment to national coverage by 2012/13.
Responses to specific consultation questions
Qa. Are there additional ways in which we can ensure that GPs and GP practices will continue
to play a key role in areas for which Public Health England will take responsibility
We welcome the intention to increase the role of general practice in public health, including
ensuring that public health activity is appropriately reflected in the Quality and Outcomes
Framework (QOF). We also support the proposal to include public health in the education and
training of GPs and believe this should be extended to the whole primary healthcare team.
General practice teams have a crucial role in sign-posting and referring to health promotion
programmes and services, for example to promote physical activity and healthy eating. GP
consortia and DsPH will need to work closely together to ensure that there is clarity around
how, and from whom, these services are commissioned and funded.
Qb. What are the best opportunities to develop and enhance the availability, accessibility and
utility of public health information and intelligence
We welcome the recognition that ‘Public health evaluation and research will be critical in
enabling public health practice to develop into the future and address key challenges and
opportunities’. There should be a statutory duty to promote public health and health
research throughout the new public health and health structures, including GP consortia.
The focus on localism must not impede the commissioning of national public health research.
There is currently a gap between public health research and the provision of public health
services. Local commissioning structures and providers will need effective
relationships with both the National Institute for Health Research (NIHR) and academic
institutions that conduct research.
21 Petersen S., Peto V., and Rayner M. (2003). Congenital heart disease statistics
22 Royal College of Physicians (2010). The National Audit of the Management of Familial Hypercholesterolaemia
7 Submitted 31 March 2011

Public health knowledge management systems are also crucial to ensure evidencebased
practice. The roles of information officers should be protected, maintained and
developed. Frameworks and guidance on the evaluation of ‘what works’ should also be
developed and disseminated.
Clarification is needed about the future of public health observatories.
Open access to independent reliable national and local data on population health needs
and outcomes, including the Public Health Outcomes Framework, will be an important
mechanism for enabling genuine scrutiny and accountability. This should include making
available local data on physical activity levels among children and young people and
maintaining the Local Tobacco Profiles. National lifestyle surveys should continue to be
supported and funded so behaviour trends in different population groups can be monitored.
We are pleased to see that the National Child Measurement Programme will continue.
We are pleased that the Health and Social Care Bill requires GP consortia and the NHS
Commissioning Board to have regard for Joint Strategic Needs Assessment (JSNAs) when
drawing up their plans. There must be a clear, publicly accessible audit trail leading from
population JSNA, through to service design, service implementation, monitoring and review.
The effectiveness of this process will depend on close partnership working and data-sharing
between DsPH and GP commissioning consortia.
Qd. What can wider partners nationally and locally contribute to improving the use of evidence
in public health
During this period of significant organisational change, the voluntary sector and academic
institutions remain a constant and lasting source of expertise and evidence on the
effectiveness of public health interventions. As activity is increasingly devolved to a local level,
national voluntary sector organisations also play an important role in identifying and
disseminating local good practice, and exploring the needs of population groups across
organisational boundaries.
Case study – The work of the British Heart Foundation to improve heart health
The BHF delivers a number of innovative community outreach projects that work directly with
communities with a high risk of heart disease. Through our £9 million Hearty Lives 23
programme we are working in partnership with health, local authority and community
organisations to tackle inequalities in heart disease. In Bristol, for example, we are investing
£100,000 in helping children’s centres throughout the city to encourage families to adopt
healthier lifestyles, working in close partnership with NHS Bristol and Bristol City Council.
We also run outreach projects that promote healthy lifestyles to the South Asian population. In
2010, the BHF attended ten Melas - South Asian cultural fairs - across the country, and
through our annual Ramadan campaign we help people from Muslim communities to make
positive lifestyle changes including through working with local mosques.
Over the last two years we have also been running projects and developing resources to raise
awareness of heart health among African Caribbean communities, including through working
with black barber shops, and at events including the Afro Hair and Beauty Show and the Jerk
Cookout Festival.
Meanwhile, our annual Food4Thought campaign aims to encourage 11-13 year old children to
take greater responsibility for their health, and to create an environment where bad food
influences are minimised. This year will be the sixth year of the campaign which has involved
23
For more information, please see: www.bhf.org.uk/heart-health/how-we-help/in-your-area/hearty-lives.aspx
8 Submitted 31 March 2011

‘Ultimate Dodgeball’ events, and children creating their own ‘Yoobots’ - a mini digital version of
themselves that shows how choice of food and lifestyle affects health 24 .
The BHF Health at Work programme 25 provides free ideas, information, tools, and advice for
organisations to develop their own ‘health club’ at work. Our guides suggest simple steps that
workplace health coordinators can take to help support their workforce to make positive
lifestyle changes.
The BHF also funds a number of specialist organisations which focus on public health
research. This includes the BHF National Centre for Physical Activity and Health at the
University of Loughborough, and the BHF Health Promotion Research Group at the University
of Oxford.
In addition, we play a key role in translating evidence into practice through the provision of
information and support for patients and the public. We produce a wide range of free tools,
resources and services that educate and empower people to protect and improve their heart
health, including the BHF Heart HelpLine 26 and free Heart Matters 27 service (providing
members with a magazine and online lifestyle check).
The different commissioning bodies, including Public Health England, the NHS
Commissioning Board and GP consortia should engage with the voluntary sector so
they can share insights, evidence and expertise.
National and local commissioning policy and guidance should also recognise the role of major
national charities as commissioners and co-investors in the health and wellbeing of local
communities, and not just as providers of services.
Charities, patients, the public and academic institutions should be fully engaged and involved
throughout the commissioning cycle, from the development of the Joint Strategic Needs
Assessment through mapping needs against existing provision, service planning, re-design,
service specification and contracting, delivery, monitoring and evaluation. Health and
Wellbeing Boards should be responsible for ensuring that this happens.
To play our part in the Big Society and invest resources most effectively charities like the BHF
must have open access to independent data on trends in population behaviour, for example
through the Public Health Outcomes Framework and National Lifestyle Surveys.
The BHF would welcome the opportunity to provide additional information to support the
Government in developing and implementing its proposals.
For more information, please contact policy@bhf.org.uk
24 For more information, please see: www.yoobot.co.uk/yoobot.html
25 http://www.bhf.org.uk/Thinkfit/default.aspxpage=0
26 HelpLine team is made up of cardiac nurses, heart health advisers, and a bereavement counsellor, and around 3000 enquiries
each month are handled by telephone, email, and letter
27 For more information, please see: www.bhf.org.uk/heart-health/how-we-help/information/heart-matters.aspx
9 Submitted 31 March 2011