1. “Fit and Well – Changing Lives 2012 – 2022” Michael Mc Bride Chief Medical Officer DHSSPS
Fit and Well – Changing Lives is the new cross – cutting Public Health strategic framework for Northern Ireland.
The consultation document, which is intended to be formative, was launched for public consultation on the 19th July. The period of consultation will last until 31st October 2012.
The document puts forward proposals for an updated strategic direction for public health for the next ten years, to reinvigorate action on current and future public health and wellbeing priorities.
This brings together actions at a government level in a reinforcing framework, and is intended to guide implementation at regional and local level.

2. Background - IFH
Investing for Health shift the emphasis by tackling the factors which adversely affect health & perpetuate health inequalities
Action to address the wider determinants of health
Framework based on intersectoral partnership at government & local levels
Goals
to improve health status of all our people
to reduce inequalities in health
NOTES FOR USERS : These first slides provide the background and context - SEE CHAPTER ONE, ‘FIT AND WELL – CHANGING LIVES’
By way of background, it is intended that Fit and Well – Changing Lives will succeed and build on Investing for Health, the Executive’s first cross – cutting public health strategy which was published ten years ago in 2002.
IfH recognised that health and well-being is largely determined by the social, economic, physical and cultural environment and also that health policy up until that time had predominately concentrated on the treatment of ill health rather than on its prevention.
Key features were that it was an
An overarching strategic framework which aimed to inspire a shift in emphasis and to bring about better co-ordination of effort around identified priorities for health improvement
Goals ….by tackling the wider determinants of health to bring about action on the ‘causes of the causes’
Founded on the need for collaboration and partnership working amongst all those with a contribution to make, including local communities

3. IFH Review 2009/10 – key findings
Need for public health strategy based on ethos and principles of IFH
Updated for emerging social, economic and legislative developments/new bodies of evidence
“Whole systems” approach required
A strategic review of Investing for Health was conducted in 2009 /10 – it reported that much of the strategy’s approach remains relevant, for example the focus on wider determinants of health, and that there are positives to build on – for example the purpose and sense of direction that it gave to those within and outside of health, the inclusive approach to development and delivery, and it reported a strong local ownership and commitment even now.
It also highlighted challenges - for example disconnection at local and regional level, but a particular challenge at regional level, and that a whole systems approach in which activity is monitored and evaluated is required.
In broad terms the review concluded that there is a need for an updated public health strategy which takes account of the current socio – economic context and new bodies of evidence.

4. Barton and Grant – health map for the local human habitat – illustrates the various layers of influence which shape health and wellbeing

5. As well as the Investing for Health Review providing a starting point for the development of a new framework, we obviously were aware of the major new body of evidence which emerged from the work of Marmot and his strategic review of health inequalities in England. This is one of the key bodies of evidence which has been considered in looking at updated strategic direction.
Marmot had made 6 key policy recommendations based on the social determinants of health
Based on research findings his recommendations include that Early Years/Give every child the best start should be given higher priority.
Marmot also evidences the importance of communities for physical and mental health and well-being.
The physical and social characteristics of communities and the degree they enable and promote healthy behaviours all make a contribution to social inequalities in health.
Marmot also highlighted the importance of adopting a lifecourse approach and that whilst highest priority should be given to Early Years including the pre- natal stage, there is much to be done throughout the various stages of life through school, and on into working age etc, .
It would be very hard to ignore this evidence and others eg the report of the WHO Global Commission on the Social Determinants of Health etc
So as starting points the new framework seeks to build on what it is suggested is still relevant about the current approach and also new bodies of national and international evidence – in particular the Marmot work, and a growing body of evidence on early years for example.
The first step towards the development of new strategy was to seek the agreement of Health Minister and Executive colleagues which we did around the summer of 2011.
At a meeting of the Ministerial Group on Public Health the scope for a new framework was agreed and also processes for working with other departments in its development. We also agreed to set up a cross – sectoral Project Board to advise and support the process ( included representation from HSC, Local Government, Voluntary sector and others)

6. Healthy life expectancy
This looks at the number of years an individual might expect to live in good health. Between and it increased in NI for both males and females by around 1.4 years.
However NI generally fares worse than other UK countries – the gap between HLE in NI and England doubled over this period to 3.0 years for both males and females.
This analysis is based on self – reported data – the differences may to an extent be the result of differences in perceptions of health between countries. Census 2011 figures will hopefully help with further analysis.

7. WIDER DETERMINANTS
More than 1 in 5 children growing up below the poverty line
44% of households in fuel poverty (76% in 75 years+ age group)
Unemployment rate 8.2 %:
45.5% unemployed for 1 year +
Rate for yr olds 22.3%
This looks at some information on the wider determinants of health
The report “Broke - not broken” published by Prince’s Trust reported that 1 in 5 children here are growing up in poverty ( level of relative income poverty for children in 2010/11 was 21%).
High levels of fuel poverty here – 2009 House Condition survey reported 44% of households ( 302,310 households) are in fuel poverty [ need to spend more than 10% of their income on energy costs]
- there is a link between living in cold damp homes and a number of conditions eg respiratory disease, cardiovascular disease and poor mental health.
Unemployment has a significant impact on both physical and mental health. Long term unemployment increases the risk of self harm, suicide etc, and has an enduring affect over the lifecourse. The figures on this slide have been taken from the May – July 2012 Labour Market bulletin 7

8. Life expectancy by Deprivation Northern Ireland 2008‐10
The influence of social conditions and lifestyle behaviours is evident when we compare life expectancy and other health outcomes across geographical areas and population groups as the following slides illustrate
This example shows life expectancy at birth by deprivation decile. [ Under IFH we compared most deprived quintile against NI average] This lets us compare and illustrates the gradient between the worst and best deciles. Sir Michael Marmot argued that all those beneath the very best off are in need, and that to reduce the steepness of the gradient requires actions that are universal, but proportionate to the level of disadvantage – ie some need a more intense level of support.
Note the steeper gradient across the deciles for males. The gap between most and least deprived decile for males is 12 years, and for females 8 years.
This shows the scale of the challenge.

9. Decomposition of the Life expectancy gap between the most deprived areas and NI overall 2006-08
This illustrates the breakdown of the reasons for the Life Expectancy gap ( most deprived v NI overall ).
Source : NI Health and Social Care Inequalities Monitoring system.
The gap is due to higher mortality rates in deprived areas for –
Males – CHD, suicide, lung cancer, respiratory disease, chronic liver disease and other cancers
Females – lung cancer, respiratory disease, CHD and other cancers

10. Standardised Death Rate (SDR) due to cancer for population aged under 75 years by Deprivation Decile,
This and the next slide illustrate the social gradient in relation to death rates under 75 due to cancer and lung cancer.
Cancer related mortality in the most deprived decile was more than twice that in the least deprived

11. Standardised Death Rate (SDR) due to lung cancer for population aged under 75 years by Deprivation Decile,
And if we look specifically at lung cancer related mortality – the rate in the most deprived decile was more than five and a half times that in the least deprived.
[ Additional Information from NIHSCIMS 4th update bulletin 2012]
The regional standardised death rate due to cancer has reduced over time, however in comparison the rate for cancer for the most deprived areas saw slightly smaller reductions in mortality rates than the region
Between 03/07 and 06/10 there was little change in the lung cancer death rate for the region overall [ 47 deaths per 100,000 population both at the start and at the end of the time series.] In respect of lung cancer the rate in the most deprived areas rose by 3% and stood at 81 deaths per 100,000 population. Lung cancer death rate in rural areas was 35 deaths per 100,000.
There have however been notable improvements in the inequalities gaps in all cancer and lung cancer incidence rates however it should still be noted that despite relative improvements many of these observed gaps still remain sizable. [ Standardised Incidence Rates (SIR )for all cancers in the most deprived areas remained higher than the regional average however the gap reduced substantially over the timeframe from 21% higher in 93 – 99 to 7% higher in

12. Health Challenges for NI
Demographic – ageing population - growth in chronic conditions
Higher rates of preventable illness and premature deaths in most deprived areas
Correlations with wider determinants such as educational attainment
“At risk”/vulnerable groups
NOTES FOR USERS : these slides summarise the Health Challenges – see Chapter 4
It was also important to take account of the current context in terms of Health Challenges for Northern Ireland – for example -
- demographic trends – the growing ageing population
- that while in general health has been improving, that rate of improvement is not the same for everyone.
- health outcomes are generally worse in the most deprived areas in NI when compared with those witnessed in the region generally and large differences (or health inequality gaps) continue to exist for a number of different health measures [– for example life expectancy, drug related and alcohol related mortality, suicide, teenage births, smoking during pregnancy, respiratory mortality]
- it also acknowledges that some key determinants show similar trends eg educational attainment
And highlights particular issues for some at risk groups such as those with disabilities, vulnerable children such as looked after children, migrant populations, homeless as well as those living in deprived areas.
The key focus remains on the uneven distribution of health – and to quote Minister Poots in the Assembly recently “ This isn’t a sprint, it’s a marathon.”

13. Health challenges
Health impact and social cost of alcohol as much as £679m per year
1 in 5 adults in NI have a mental health condition (anxiety/depression)
59% of adults were either overweight or obese
Tobacco is the greatest cause of preventable illness and premature death

14. “Fit and Well – Changing Lives”
Based on values, principles and broad aims of IFH
Strategic/high-level and cross-government
Focus on wider social determinants
Emphasis on health inequalities/‘social gradient’
Engagement/empowerment individuals, families, communities
Life course approach
Outcome focused
 Notes : see chapter six – Strategic Framerwork
“ Fit and Well – Changing Lives” contains proposals for an updated strategic direction for the next ten years.
Informed by the outcomes of the IFH Review, consideration of the evidence, and in the context of the health challenges, it was agreed the framework would incorporate the following features –
Firmly based on values, principles and broad aim of Investing for Health – ie to improve health and reduce health inequalities
It is a Strategic overarching framework – bringing together a strategic direction, linking and reinforcing relevant government policy / strategy as they relate to the determinants of health
Emphasis on health inequalities but mindful of ‘social gradient’
Life course approach
Key strategic priorities are identified
Outcome focused (- outcomes are the changes, benefits or other effects that happen as a result of policies or activities, the challenge is to focus on impact and not just on output.)
A challenge is to align with other major policy developments as they are also moving forward, for example Delivering Social Change. In addition , the capacity and efficiency of Health Systems must be seen as an important health determinant – therefore this framework must also work alongside and inform major developments within the Health Sector, including Transforming your Care

15. VISION
“Where all people are enabled and supported in achieving their full health potential and well-being.” This is intended to build on the aim to improve health and wellbeing and reduce inequalities in health.
Building on the aim to improve health and wellbeing and reduce inequalities in health, the framework will move NI towards a vision –
“Where all people are enabled and supported in achieving their full health potential and well-being.”
This vision is around creating the conditions for individuals and communities to take control of their own lives and requires social action.

16. Values Health as a fundamental human right
Policies pursue equality of opportunity and promote social inclusion
Individuals and communities fully involved in decisions relating to health
All citizens have equal rights to health, and fair /equitable access to health services and health information according to their needs
Action under Investing for Health was guided by a set of values and principles - the Investing for Health Review reaffirmed that these were still relevant and it is therefore proposed to retain these.

17. Fit and Well – Changing Lives
The strategic framework can be graphically depicted as shown, with interventions focussing on achieving outcomes based on meeting the specific needs of each lifestage and to assist transition between these. A key development/ change reflected in the new framework is that it is built on the lifecourse approach with two underpinning themes which cut across the lifecourse.
This recognises that biological factors, developmental and other experiences set individuals onto trajectories that influence health and wellbeing, and competence over the lifecourse and that life’s transitions can affect health by moving people onto a more or less disadvantaged path ( – people who have been disadvantaged in the past are at greater risk. )
At population level the framework emphasizes the importance of developing people’s potential and coping skills and the importance of creating supportive environments which will support and promote health.
It also acknowledges the major influence of the communities to which we belong and the importance of engaging and promoting supportive and sustainable communities as a strategy for tackling the issues that affect health inequalities.
This is an underpinning theme, along with building healthy public policy, which aims to ensure that departments take potential health impacts into account as part of the policy development process.

18. Policy aims Life course Themes Give every child the best start
All children and young people to develop the skills and capacity to reach full potential and have control over lives
Young adults to grow, manage change and maximise potential
Working age adults to have a full and satisfying life and social wellbeing
People in later years to have a satisfying and active life
Themes
Promote healthy safe, sustainable places and thriving communities
Ensure health is a consideration in the development of public policies
This slide illustrates the proposed Policy Aims for each lifecourse – essentially to support everyone regardless of age to reach their full potential and underpinning theme

19. Each life stage and underpinning theme
a policy aim
long term outcomes to aspire to
outcomes to achieve by 2015 ( linked to budget period)
Outcomes are based on encouraging action:
Securing safe and supportive environments
Seeking to maximise potential
Promoting good physical and mental health and wellbeing
Notes for Users – see Chapter seven – Strategic Framework Themes and Outcomes
Policy Aims are identified for each of 5 age ranges and underpinning themes
And long and shorter term outcomes are also identified for each [- outcomes are the changes, benefits or other effects that happen as a result of policies or activities, the challenge is to focus on impact and not just on output.]
These outcomes to be achieved are grouped around -
Creating supportive environments
Personal development and capacity building and
Promoting good health and wellbeing.

20. Example - Give every child the best start
Long term outcomes:
- Children have safe and supportive family, living, play and learning environments
- Children are prepared for school and later life
- Children to have achieved their full potential (cognitive, linguistic, emotional, behavioural and physical)
To take one example and to give you a flavour – under “Give every Child the Best Start” – these have been identified as the Long term outcomes.
As you can appreciate these are aspirational - there are many actions that need to be taken, and many agencies, organisations and individuals that need to be involved, in working towards these. But the idea is that these provide direction to galvanise actions.

21. Give every child the best start
Shorter term outcomes: - positive parenting supported - high quality Sure Start services in areas of disadvantage - all children and families offered full range of health protection, health promotion, surveillance, screening and immunisation programmes and needs assessed….
A range of shorter term (up to 2015) outcomes which will move us towards achieving the long term outcomes have been discussed and agreed with departments – examples include the ones in the slide ….
This is in chapter 7 of the document.
Similarly there are long and shorter term outcomes for the other age groups also, which focus on the needs of each stage of life.

22. Sustainable Communities
Healthy, sustainable and safe physical environments and supportive services
Improved community capacity and social capital
Community health and wellbeing improved, particularly those of most disadvantaged areas
Sustainable Communities is an underpinning theme which cuts across the lifecourse – these are the long term outcomes proposed to direct action
This acknowledges that people’s health and wellbeing is influenced by the physical and social environment in which they live .
It includes effects of chemical, physical and biological hazards - radiation and noise for example. Includes also the quality of housing and neighbourhood environment, access to green space, transport etc. It also includes climate change to which many communities will require to adapt [ For NI likely to be those associated with more frequent extreme weather events particularly flooding , higher summer temperatures including heatwaves and water shortages – some people may be more vulnerable eg older people, people with disabilities, lower income groups.]
This also acknowledges that as well as physical factors, the communities to which people belong have a significant impact - support from families, friends and communities is associated with better health. Social capital – the links that connect people – can promote resilience and support against difficulties and help bring added control over people’s lives.
Social stability, community safety and good relations all contribute to a society which supports good health and wellbeing.
The other underpinning theme is “Building Healthy Public Policy” – this is to encourage that health is a key consideration in all public policies.
The long term outcome is that “ Public policy supports improved and equitable health and wellbeing outcomes.”

23. Strategic Priorities Early Years Supporting Vulnerable People and
Communities
So that is the broad framework – based on 5 lifestages and two underpinning themes.
In addition and in line with evidence on tackling health inequalities, two strategic priorities have been proposed ie
Early Years
Supporting vulnerable people and communities
There is now overwhelming evidence nationally and internationally that children’s life chances are most heavily predicated on their development in the first years of life.
It is vital that children are given the best possible start in life in order to break the cycle of disadvantage that correlates to poor outcomes throughout life and across generations. This starts from ante natal care, and includes childhood development, support for good parenting and opportunities for learning.
Vulnerable People and Communities
This priority acknowledges that more focused effort will be required to reduce health inequalities experienced by vulnerable people and communities including those living in deprived areas.
In respect of vulnerable people, some population groups are identified eg people with disabilities. It is not intended to be an exclusive list but given as examples to provide direction eg – in specific geographical areas needs of particular groups may be greater/ lesser eg ethnic minorities may be concentrated in particular geographies. It will be for local commissioners and partnership arrangements to identify and address specific need.
For example – Looked after children are at greater risk of poor health and other adverse societal outcomes, for example in education and involvement in crime
People with disabilities are at greater risk of poverty and social exclusion, and poor health including poor mental health
Homeless people have complex needs and are at considerable risk to their physical and mental health

24. Cancer prevention 10 year Tobacco Control Strategy
Skin Cancer Prevention strategy
A “Fitter Future for All” – Obesity Prevention Strategy
New Strategic Direction for Alcohol and Drugs
In respect of cancer prevention, “ Fit and Well – Changing Lives” overarchs and reinforces the aims and aspirations of those issue specific strategies already in place to address risk taking behaviour such as smoking , alcohol misuse, unhealthy diet, sedentary lifestyle [may also want to mention Screening programmes] etc. by emphasising
the need to address the wider determinants that influence these behaviours – and work in partnership to do so
the impact of the determinants at each stage of development from early childhood…. through to later years.
the need to address the social gradient ( universal services and more targetted action towards those more vulnerable)
The framework emphasises the need to work across departments and other sectors to create the conditions for individuals and communities to enable people to take control of their lives.
It incorporates the key outcomes anticipated from the issue specific strategies – for example
Eg – reduced numbers of children and young people taking up the smoking habit
Increased awareness of care in the sun and risks associated with sun bed usage
Reduction in the % of adults overweight and obese and includes as a proposed outcome for example – “ throughout life people have access to contemporary and appropriate public health advice, information and services and are supported to develop the skills to manage theori own health, including the ability to manage medicines effectively.

25. Priority Areas for Collaboration
Support for Families & Children
Equipped for Life
Employability
Volunteering/Giving Back
Use of Space & Assets
Using Arts, Sports & Culture
Notes for Users – see chapter eight – Priority Areas for Collaboration
It was acknowledged that many of the issues and outcomes which are set out in the framework reflect work already underway or planned, and on which there is already to some extent inter-departmental and interagency collaboration .
The framework needs to enhance and add value. Through a workshop attended jointly by officials of the Ministerial Group and also members of the Project Board there were 6 potential areas for enhanced joint working /collaboration identified – the benefits of which would cut across life-stages, and promote inter- generational activity. These are intended to take account of the current socio-economic context and dovetail with and contribute to the aspriations of the Programme for Government.
These areas are still at a developmental stage and are being put forward to seek views through the consultation.
1 This covers early years, childhood development and support for parenting – it would aim to enhance support through incremental development of targeted and universal programmes - for example expanding formal early learning programmes, rolling out of programmes subject to positive evaluation ( eg Family Nurse Partnership – more intense home visiting for vulnerable first time mothers), strategically expanding positive parenting programmes etc.
Closer joint working would seek to ensure providers ( statutory and community) are well connected, and would generally therefore contribute to
building capability and social capital.
2. Equipped for life aims to ensure minimum educational standards and lifeskills eg in relation managing finances, as well as health and wellbeing, and citizenship. It would refer to all population groups eg those with disabilities. It could include support for parents whose children are struggling at school. Examples – Extended school programme, Full Service provision, Parent Support Officers, Big Brothers Big Sisters
3. Promotes employability – this would look at the use of social clauses and target those who have been unemployed long term and those who are young to provide experience of work . It would include joint working arrangements between eg DEL/ Further/ higher Education and public bodies such as Health Trusts, Local Government
Working examples include the Care into Career Programme – HSCB and DEL working together to address employability needs of young people affected by care.
4 .Promotes lifeskills through Volunteering, and aims to build capacity, self esteem, promote social inclusion and intergenerational activity . Examples of initiatives are – Time to read, Time 2 Count, Time to Compute – mentoring programmes, co-ordinated through Business in the Community that link children at key stage 2 in primary schools with an adult mentor from the world of work.
5.Brings together utilisation of space and building social capacity and assets. Examples are Community Use of schools – the schools estate is a significant public resource and Public Realm schemes – enhanced civic spaces where people can meet, socialise and enjoy events
6. Would explore the potential impact of Arts, Sports, Culture on engagement, inclusion, physical and mental health and wellbeing. Examples are Arts Care – makes art accessible to patients, clients in health and social care settings
Special Olympics – sports training for children and adults with a learning disability
Sport in the Community programmes which focus on volunteer development

26. IMPLEMENTATION Partnership working remains key:
Government level [MGPH]
Regional level [Delivery Board]
Local level [ Local Arrangements?]
Whole Systems Approach required
HOW WILL THE FRAMEWORK BE IMPLEMENTED?
Given the range of factors that influence health and wellbeing partnership working will remain key – and, informed by the findings of the IFH review, the aim will be to promote a “whole systems approach”, whereby there is more coherence across the various levels at which work needs to be taken forward, with effective linkages and communication across the range of sectors and various levels of the system.
Proposal is to retain the cross departmental group Ministerial Group on Public Health under the leadership of Minister for Health but review and update its terms for reference to ensure it links with other cross – government structures. It will also need to connect with and be informed by delivery structures.
There will need to be co-ordination of regional and local level activity. Given the role of the PHA, and its regional and local level reach, it is proposed to look to the PHA to play the lead role in developing proposals for regional and local delivery – it is considered there would be benefit in having a regional delivery structure/board which could gather and disseminate best practice, monitor and report on action etc.
All of the various partners – departments and public bodies, community and voluntary organisations, business sector etc bring their specific contribution –
at government level, need policy coherence
delivery level, need collaboration and maximisation of opportunities and resources
at local level need support to identify and engage with those who are isolated, disengaged and vulnerable
Challenges to Partnership working will remain – eg
Organisational Barriers
Aligning Processes (eg planning)
Inter-connectedness
Clear responsibilities
Pooling resources
Time
[ DN COULD MAKE MENTION OF LINKAGES WITH COMMUNITY PLANNING ARRANGEMENTS AT LOCAL LEVEL]

27. Looking ahead
Need strengthened and better connected structures, at all levels
“The idea of partnership is not new but new approaches are needed if it is able to address the formidable challenge of improving health and reducing inequalities.”
Sir Liam Donaldson
We need to optimise opportunities - strengthen the STRATEGIC , REGIONAL AND LOCAL levels further and the connections between these levels of working – this is a big challenge ahead
Partnership working - perhaps best summarised in this quote from the former CMO of England

28. Monitoring , research and evaluation
Long term outcome:
Policy, research and practice supported by robust data and evidence base
Short term outcome:
Key high level indicators by Dec 2012
Notes for users : See chapter nine
We obviously need to ensure that the direction provided by the framework is well founded in evidence and that we can monitor progress over time. We anticipate needing to roll it forward again in three years time.
The framework identifies as a long term outcome that policy, research and practice are supported by robust data and evidence base – we therefore need to consider how to collaborate more closely on research and linking it in with policy development, and as a short term outcome we need to work on the identification of set of high level indicators with which to measure progress. The aim will be to include these in the final framework.
We have set up two groups on Data and Research to help us do this which include representation from NISRA, Centre of Excellence for Public Health Research, Universities, Institute of Public Health in Ireland.

29. Next Steps Consultation period ends 31st October Analysis of responses
( dhsspsni.gov.uk – current consultations)
Analysis of responses
Finalise and publish early 2013
Health Committee Evidence Review on Health Inequalities
Implementation…….
The framework is out for consultation until the end of October – all views are welcome, you can download the consultation questionnaire from the department’s website (– go to the index of current consultations, and then click on the link for the framework. Also available - there are the full and a short version of the publication.)
The aim is to analyse responses, and to re-engage with others (eg across departments, and others depending on the consultation response) to consider and make any adjustments. The Health Committee are also undertaking some work which will help inform the final framework.
The aim is to publish the final framework in early in 2013.
We will also be working to establish the structures and processes to take forward implementation.