Six impossible things

before lunch

How can we‘break the cycle’of child poverty?

Mark ReillyNHS Tees

13th January 2012

This presentation took place inEston City Learning Centre

Middlesbroughat a conference

‘Breaking the Cycle of Child Poverty’

For those not at the meeting, some slides now includeexplanatory comments

in boxes with this background colour.

Six impossible things

before lunch

How can we‘break the cycle’of child poverty?

Mark ReillyNHS Tees

13th January 2012

Helen MaureenBorn in Darlington

One of a family of 14 children

Childhood years in South Tees area

‘I was raised on drugs’

No formal qualifications

She lived in her bedroom

I eventually asked her:What would have made a difference to you?

One of two children

Childhood years in a village location

Currently studying 4 A Levels

Plans to study Psychology

Offers from four leading universities

Voluntary work in a local hospice

Sample size of n=2!Added commentWe’ll discover what Maureen said later…

Added commentOur ‘world view’ of povertyis often influenced by narrow personal experience…

Darlington

Durham

Middlesbrough

Redcar

Hartlepool

Easington

Stockton

Added commentThis map presents a wider view of poverty in the North East beyond anecdotes of cases.

‘There’s very little research that tells me what I need to do on Monday morning…’

…impossible things before breakfast?

Perhaps not so much the absence of ‘things to do’ as:

1. Ignorance of the causes (and potential remedies)

2. Misapplication of knowledge and science

3. Mismanagement of processes that matter

4. Dilution or absence of effective leadership

Added commentThis quote was fromthe Chief Executive of aCommunity Foundation.

If we are to ‘break the cycle of poverty’…then maybe WE should consider

‘Six impossible things before breakfast’"There's no use trying," said Alice; “…one can't believe impossible things.”

"I daresay you haven't had much practice," said the Queen. "When I was younger, I always did it for half an hour a day. Why, sometimes I've believed as many as six impossible things before breakfast."

Alice in Wonderland.Added commentIf we are serious about ‘breaking’ the cycleof poverty, we need to think and act differently.

The first impossible thing…Trying to remember some lessons from history

History

The first impossible thing…Trying to remember some lessons from history

Sir Donald Acheson

Publication of the Report on Inequalities in HealthLondon, November 1998

The first impossible thing…Trying to remember some lessons from history

Sir Donald Acheson

Publication of the Report on Inequalities in HealthLondon, November 1998

Sir Douglas Black

Professor David Barker

Barker’s researchon infant health

formed the basis ofthe Acheson Report

The first impossible thing…Trying to remember some lessons from history

Sherborne HouseNorton High Street

Café LilliNorton High Street

Dr George M’GonigleMedical Officer of Health

Stockton-on-Tees1924-39

The first impossible thing…Trying to remember some lessons from history

Born in Monkwearmouth in 1889

Qualified in medicine (Newcastle)

School Medical Officer in County Durham, pre-1914

Medical Officer of Health in Stockton, 1924-1939

Focused on maternal and child nutrition

His name ‘lives on’ in Poverty & Public Health (1936)

Leading reformer in pre-war period

Threatened with being struck off the Medical Register

Locally popular as, the “Housewives’ Champion”

Died in 1939, aged 50

Added commentThe work of Dr M’Goniglehas been summarised recentlyin the Journal of Public Healthby Professor Clare Bambra,University of Durham.Clare BambraLessons from the past: celebrating the 75th anniversaryof Poverty and Public Health

J Public Health (2011) 33(4): 475-476

The first impossible thing…Trying to remember some lessons from history

0

20

40

60

80

100

120

Very deprived Affluent

0

5

10

15

20

25

30

<35/- 35-45 46-55 56-65 >65/-

0

5

10

15

20

25

30

35

<35/- 35-45 46-55 56-65 >65/-

0

50

100

150

200

Portrack Ingleby

1930s 1990s

Moneyto spendon food

Mortality

2-fold 4-fold

2-fold 3-fold

Inequalities in exposure to risk & health outcomes between richest and poorest seem to persist

Added commentAlthough absolute improvements occur over time, inequalities often persist.

Professor Sir Michael Marmot

The Marmot Principles

1. Give every child the best start in life

2. Enable people to maximise their capabilities

3. Create fair employment and good work for all

4. Ensure a healthy standard of living for all

5. Create and develop healthy communities

6. Strengthen the role and impact of prevention

“Social injustice kills…on a grand scale”

The first impossible thing…Trying to remember some lessons from history

Published 2010

Added commentProfessor Marmot’s approach is to tackle inequalities by addressing riskssystematically across the life courseand especially in infancy and childhood.

The first impossible thing…Trying to remember some lessons from history

Sir Donald Acheson

Publication of the Report on Inequalities in HealthLondon, November 1998

Sir Douglas Black

Professor David BarkerSir Michael Marmot

Added commentPublic Health historyreveals patterns thatrepeat and from whichwe could learn.

The first impossible thing…Trying to remember some lessons from history

Would it be impossible…

To immortalise the vision of George M’Gonigle by:• creating an academic research unit in his name?• establishing the M’Gonigle Chair in Poverty Studies?• funding a M’Gonigle scholarship?• awarding a M’Gonigle Prize?• instituting a M’Gonigle Lecture?

We can learn from history without living in the past

The second impossible thing…Trying to improve infant feeding and health

History

Nutrition

Every week of every year…..

about 120 infants are born in Teesside…These infants go home tovery different circumstances

Before long,some of these infants are admittedto the very same hospitals often for preventable reasons…

The second impossible thing…Trying to improve infant feeding and health

Females 0‐4

Code Primary Diagnosis No.

B349 Viral infection  unspecified 447

J069 Acute upper respiratory infection  unspecified 273

A084 Viral intestinal infection  unspecified 176

J219 Acute bronchiolitis

unspecified 164

J22X Unspecified acute lower respiratory infection 145

Males 0‐4

Code Primary Diagnosis No.

B349 Viral infection  unspecified 612

J069 Acute upper respiratory infection  unspecified 402

A084 Viral intestinal infection  unspecified 253

J219 Acute bronchiolitis

unspecified 252

J22X Unspecified acute lower respiratory infection 191

Admissions to North Tees & Hartlepool hospital,2009/10 and 2010/11

Breastfed babies have:

• less chance of diarrhoea and vomiting• fewer chest and ear infections• less chance of being constipated• less chance of developing eczema• less likelihood of becoming obese in later life

Added commentRates of emergencyadmissions to hospitalin Teesside and theNorth East are amongstthe highest in England.

The second impossible thing…Trying to improve infant feeding and health

30

35

40

45

50

55

60

65

70

75

80

2008 2009 2010 2011

EnglandHartlepoolMiddlesbroughRedcar & ClevelandStockton-on-TeesGateshead

Year

Breastfeedinginitiation

rate (%)

Added commentRates in Teessideapart from Hartlepool(but from lowest level)have changed littlein recent years.Rates in Gatesheadseem to be improvingmore quickly.

Breastfeeding initiation rate (%)2009/10

73% Leeds77% Sheffield77% Mansfield

Calderdale 78%Trafford 73%Stockport 74%

North East

Added commentThere is a north-south gradient in England.

However, there are local authority areas in the northof England (above) where rates are considerably higher than Teesside.

Tees localities(black dots)

Gateshead(red dot)

Breastfeeding initiation rate (%)2009/10

Smoking in pregnancy

rate (%)2009/10

Breastfeeding initiation rate (%)2009/10

Smoking in pregnancy

rate (%)2009/10

Breastfeeding at birth

Smok

ing

in p

regn

ancy

MbroHpool R&C

Stkn

S Tyne

SundC Dur

Darlo

N’berlandG’head

Newc

N Tyne

Sheffield

Individual risks of smoking and not breastfeeding

are bad enough…

The combined risks

are devastating for optimal child health.

The second impossible thing…Trying to improve infant feeding and health

Would it be impossible…

To improve infant nutrition by:• Making a step change to achieve the England average?• Understanding why comparable areas do better?• Consolidating regional knowledge and practice?• Enhancing the roles of frontline staff?• Just getting a list of mothers needing intense support?

If breast is best, why do we settle for less?

The third impossible thing…Trying to get every child into school every day

History

Nutrition

Education

‘The best days of our lives…?

MiddlehavenBeechwoodClairvillePallisterUniversityThorntreePark EndNewcomenNorth Ormesby & Brambles FarmDormanstownSouth BankLadgateKirkleathamBrookfieldBrottonAyresomeEstonGrangetownGreshamAcklamParkCoathamLoftusBeckfieldLockwoodZetlandKaderLinthorpeHemlingtonCoulby NewhamSkeltonWest DykeTeesvilleStainton and ThorntonGuisboroughLongbeckNormanbySaltburnMartonMarton WestWestworthSt Germain’sHuttonNunthorpeOrmesby

0.0 5.0 10.0 15.0 20.0 25.0 30.0

% unauthorised absence in ward

Unauthorised absence rates, primary school children,

South Tees wards, Autumn term 2006

We know that some childrenare absent from school one day in every six…

MiddlehavenBeechwoodClairvillePallisterUniversityThorntreePark EndNewcomenNorth Ormesby & Brambles FarmDormanstownSouth BankLadgateKirkleathamBrookfieldBrottonAyresomeEstonGrangetownGreshamAcklamParkCoathamLoftusBeckfieldLockwoodZetlandKaderLinthorpeHemlingtonCoulby NewhamSkeltonWest DykeTeesvilleStainton and ThorntonGuisboroughLongbeckNormanbySaltburnMartonMarton WestWestworthSt Germain’sHuttonNunthorpeOrmesby

0.0 5.0 10.0 15.0 20.0 25.0 30.0

% unauthorised absence in ward

Unauthorised absence rates, primary school children,

South Tees wards, Autumn term 2006

We know that some childrenare absent from school one day in every six…

Not in education or employment

Added commentAbsence from schoolis strongly associatedwith young people not being in being further education or employment.

The third impossible thing…Trying to get every child into school every day

Headline findings

The reading, writing and numeracy attainments of this age group at the top end are among the best in the world.

But more needs to be done……about 17% of young people aged 16–19 have poorer literacy, and about 22% have poorer numeracy, than is needed for full participation in today’s society.

The third impossible thing…Trying to get every child into school every day

Headline findings

The reading, writing and numeracy attainments of this age group at the top end are among the best in the world.

But more needs to be done……about 17% of young people aged 16–19 have poorer literacy, and about 22% have poorer numeracy, than is needed for full participation in today’s society.

Added commentSome companies find that some school leavers are insufficiently prepared for basic transactions in the workplace.

Added commentThere is no shortage of evidence of the effectiveness or appropriateness of interventions to improve literacy.

Maureen

‘If you haven’t got a routine… you’ve got nothing’

What would have made a difference to you?

She didn’t want more moneyShe didn’t want more attentionShe didn’t want any sympathy

She just wanted to be made to go to schoolAND to have a routine

Added commentWhat would have made a difference to Maureen costs little or nothing.

Source: University of Teesside

I started school with poor literacyand numeracy and fell in with abad crowd…

I felt spoken down to and I wasn’t inspired

David Wilson-Stonestreet

was expelled from school aged 17

with one GCSE grade D

Source: University of Teesside

David Wilson-Stonestreet

was expelled from school aged 17

with one GCSE grade D

Now, he hasBA (Hons) in English

and he’s a teacher in Teesside

Without support from my wifeand belief in myself I couldn’t have achieved this…

Added commentDavid’s inspiring story demonstrates what can be achieved in adversity subject to ability, self- belief, encouragement and support…

…it can be done!

The third impossible thing…Trying to get every child into school every day

Would it be impossible…

To improve attendance at school by:• Making a step change in ambition to achieve 100%?• Investigating the weakness of current processes?• Tackling poor literacy (given 11 years of education)?• Finding other ‘Davids’ for mentorship and leadership?• Just getting a list of children who are ‘not in school’?

If you haven’t got a routine, you’ve got nothing

The fourth impossible thing…Trying to increase income for people in need

History

Nutrition

Education

Income

Again, poverty rates particularly increase among:

• families with three or more children; • households with younger children; and • those people living in private rented accommodation,

all of which are groups with above average levels of child poverty already.

…child poverty is set to increase between 2010/11 and 2015/16 by around 400,000 to 500,000.

The fourth impossible thing…Trying to increase income for people in need

Unclaimed benefitsin Teesside alone

could total£65 - 100 million

per year

Added commentVast amounts of money that are allocated to people with legitimate needs and entitlements remain unclaimed every year.

It would be cost- effective to allocate resources locally to maximise the uptake of benefits in all localities.

The fourth impossible thing…Trying to increase income for people in need

Would it be impossible…

To improve household income by:• Making a step change in uptake of entitlements?• Focussing on those with the greatest needs• Resourcing an effective system to improve uptake?• Advocacy of a system to pursue non-claimants?• Just getting a list of entitled people who don’t claim?

More people miss out on benefits than ‘scrounge’ them

The fifth impossible thing…Trying to do the right thing first time, every time

History

Nutrition

Education

Income

Methods

‘I told you them chickens was organised…’Mr Tweedy to Mrs Tweedy as she heads to her doom

Added commentThere is no substitute for systematic and consistent approaches to achieve complex or ‘impossible’ tasks.

The fifth impossible thing…Trying to do the right thing first time, every time

How to address poverty of adults who were children…when the war on child poverty was first declared…

The impact of poverty on health and wellbeingrequires a response as if we are engaged in war

Professor Sir Michael Marmot

“Social injustice kills…on a grand scale”

Added commentIf Professor Marmot contends that social injustice (including child poverty) ‘kills on a grand scale’, then a response commensurate with that challenge to society is required.

The fifth impossible thing…Trying to do the right thing first time, every time

‘Knowledge is the enemy of disease…

the application of what we know will have a bigger impact than any drug or technology likely to be introduced in the next decade…’

Sir Muir Gray

Added commentWe need to be more effective with our own application of knowledge to reduce poverty and prevent disease…

2012 2015 2018 2021

Gestation from intervention to outcome

1

2

3

Poverty reduction requires more than one club golfing…

Example: Income maximisation

Example: Breastfeeding

Example: School curriculum design

Proposals to reduce poverty must take account of:1. Burden, distribution and severity of need2. Appropriateness and acceptability of intervention3. Efficiency and effectiveness of intervention4. Staging and duration of interventions

Many things needto be done but the

timescales to achieve better outcomesdiffer greatly…

The fifth impossible thing…Trying to do the right thing first time, every time

2012 2015 2018 2021

Gestation from intervention to outcome

1

2

3

Poverty reduction requires more than one club golfing…

Example: Income maximisation

Example: Breastfeeding

Example: School curriculum design

Proposals to reduce poverty must take account of:1. Burden, distribution and severity of need2. Appropriateness and acceptability of intervention3. Efficiency and effectiveness of intervention4. Staging and duration of interventions

Many things needto be done but the

timescales to achieve better outcomesdiffer greatly…

The fifth impossible thing…Trying to do the right thing first time, every time

Added comment… and organise our efforts into an integrated and well-structured plan.

The fifth impossible thing…Trying to do the right thing first time, every time

Would it be impossible…

To develop a plan:• That addressed complex needs with warlike response?• That harnessed knowledge & skills untapped so far?• That scaled up ‘initiatives’ into systematic processes?• That enhanced effective advocacy and lobbying?• That included inputs from those at ‘the front’?

A workable plan is better than a grand aspiration

History

Nutrition

Education

Income

Methods

Leadership

The sixth impossible thing…Trying to secure collective leadership

Ormesby BankMiddlesbrough

Added comment… the legacy of inadequate prevention;disjointed planning; and changing leadership may lead to gross inequalities in health and risks to health.

The ultimate expression of inequalities is seen in large differences in life expectancy within short distances in communities.

Nunthorpe

Marton

Park End

Pallister

Men Women

Ormesby BankMiddlesbrough

Nunthorpe

Marton

Park End

Pallister

The gradient of inequalities in health

74

72

79

82Life expectancy reduces by

2 yearsfor every milefrom suburb

to centre

75

77

86

84

Lifeexpectancy

Men Women

Ormesby BankMiddlesbrough

The sixth impossible thing…Trying to secure collective leadership

History

Nutrition

Education

Income

Methods

Leadership

Attributes of leadership

Style of leadership

Extension of leadership

‘Like slavery and apartheid, poverty is man-made and it can be eradicated

by the actions of human beings’

Nelson Mandela

Added commentWe need to consider how strong leadership can be developed and extended to a variety of people (professional and wider public) to address the challenges.

Tackle the need for an incisive plan

Tackle the poverty of ideas

If we have no greater vision totackle poverty than to meet targets

then we should ask others todevelop the vision on our behalf …

If we don’t believe that we can make a step changewe could delegate responsibility

and authority to those who can…

If Gateshead or Sheffield can make a big difference,

then we should try find out nowhow that’s been done…

Tackle the impact of our leadership

History

Nutrition

Education

Income

Methods

Leadership

Six impossible things…The End of the Beginning!

‘No bird soars too high……if he soars on his own wings’

WH Blake

Doing just a little bit more of the same simply won’t be enough…

A warlike response to the impact of povertyrequires different attitudes and actions.