LOOKING BACK
The theme for the charities 150th Anniversary and AGM could not be more fitting given the history of the charity, the current crisis in health and social care and the turbulent economy.
Victorian London was the best and worst of places. It was a time of change and of challenges to established interests; commercial, political and medical. There was a growing conviction that a better society might be shaped by the forces of philanthropy, thrift and public policy.
In 1873 a collective will for change brought together the great, the faithful and the reformer to establish a Metropolitan Hospital Sunday Fund (MHSF) for London. This was a time of major reform in public health and welfare and within a year the new Public Health and Factory Acts became law, a national insurance system was planned and Bazalgette’s sewers were under construction. Progress was not uninterrupted and life for the sick and poor of London remained perilous. Indeed it was hard enough for all, as a plague of rats in St George’s Hospital in Belgravia closed it for three months in 1874.
The idea behind ‘Hospital Sunday’ Appeal actually originated in the 1700s with chapels setting aside funds from a charity sermon on one Sunday a year for local hospitals. The MHSF’s inaugural annual report noted how beneficiaries might be “induced to associate together to secure…..medical help in time of need as a matter of right rather than to be so constantly dependent on aid.”
Capturing both the prevailing Victorian social attitude of self-help with a call for a universal system of health and social care.
During the early 20th century the MHSF worked closely with the voluntary and private healthcare system, providing funds to hospitals. These were largely used to purchase medical aids and equipment including artificial limbs, false teeth, spectacles and surgical appliances. In 1937 the Prime Minister praised donors generosity and civic duty as reflecting “a form of social service deeply implanted in our people”
The post war Beveridge report heralded hope for the future, epitomised by the introduction of the NHS in 1948. This led to an expansion of public health initiatives and a recognition of a new social contract between the State and the individual that guaranteed universal health care funded through taxation.
In the latter half of the 20th century, despite the efforts of its members, the Appeal began to lose some momentum as a result of dwindling congregations and competition from specialist charitable health care providers. The many iterations of the appeal show it trying to keep pace with this rapidly evolving health care system. In the 1990’s the charity began a new partnership with Peabody which led to the building of the Sundial day centre a major investment for a relatively small charity. Today the charity continues in its original mission to provide for the ‘sick poor’ through its Samaritan grants and by funding community led health projects that can fill gaps in public services.
Victorian London was a place of acute social division and injustice and for many it remains so today. The city is also a crucible for innovation often built on important lessons from the past.
MEDICAL OFFICER OF HEALTH (MOH) REPORTS
Ross MacFarlane, Research Development Specialist at the Wellcome Collection, reflected on 120 years of Medical Officer of Health (MOH) reports. These are part of the Collection’s extensive archives covering the period from 1850s to 1970s. The website ‘Taking London’s Pulse’ was launched 2013 as a searchable, freely available, digital resource attracting great interest and inspiring, amongst others, Heidi Thomas, script writer for the TV series ‘Call the Midwife’.
“If you go back to the 19th century, every part of the country had a Medical Officer of Health, and every year they would write an annual report on the health of their local communities”
The Medical Officer Reports are valuable social documents and contextualise our understanding of the social determinants of health, those non-medical factors that influence health outcomes. The reports are powerful testimony of how poverty and want shape our health and how services could be improved,‘ so far as they relate to the public health making thereon such practical suggestions’
The requirement for officials to report on the quality of living conditions was revelatory and led to many a call to action. The importance of accurate statistical information is captured in the reports. The use of data to plot the improvements in, for example infantile death rates, underpinned improvements in public health.
The reports demand swift action at a local level to combat outbreaks of infectious disease. The narrative style of the reports read like a detective’s notebook.
‘an investigation conducted at the time showed a special incidence of the disease upon houses supplied with milk coming from a milk vendor in the Parish, and who received his milk from five sources. It was also found that there was a still greater incidence upon houses supplied with milk coming from a particular farm. ‘ St Pancras 1865
MOH and their staff were tenacious in tracking outbreaks of disease back to their source. This at a time of rapid urban development such as the expansion of the railways which accelerated the movement of goods which allowed disease into the city. This raised wider questions, such as how to transport perishable goods, store food safely and improve working conditions. The efforts of colleagues in sanitary inspection was greatly valued. A graphic report on tracing rotten food reveals how 68 trunks of haddock in putrid condition were uncovered. An attempt to condemn the goods met with resistance and a courageous response from the public health officials,
“ it was not without great difficulty -for the men were very violent – that we succeeded in seizing one trunk of the haddocks’. This was condemned by the Magistrate and led to future inspections taking place ‘without molestation from employees of others’. Bethnal Green 1870
A prominent public health message was essential. The use of a mobile cinema to take this to the public demonstrate the importance of good communication and the use of new media. Advice clinics encouraged and sometimes cajoled the public to improve health. The 1920s saw the State take responsibility for urban public health. By the 1950s lectures and talks were given to audiences, both great and small, generating a good deal of interest and not without dissent from hecklers. Hearts and minds of a sceptical public still to be won.
The reports capture a growing sense of civic pride. MOHs were rooted in their local area, aware of its history and cultural identity. This local knowledge enables researchers to track changes in working and domestic life over time. Council officials were making change at local levels and proud of their achievements. It is worth reflecting on how the role of ‘public servant’ was valued and how at odds this can seem in today’s political culture.
“Over the decades, and often imperceptibly, every home, street and workplace was shaped by the work of Medical Officers of Health (MOHs)”
But good as they were MoH could be idiosyncratic, performance patchy and the information far from complete. However, as Sir Mark Walport former Govt Chief Scientific Advisor astutely observed during the 2023 UK Covid enquiry.
‘if you look at the history of public health there has been a long-standing decline in our capacity to fight infectious diseases………….if you go back every part of the country had a medical officer of health…largely focussed on infection.. we had lost that capability,’.
POVERTY & HEALTH TODAY
The Magpie Project provides support for mums of under-fives in temporary accommodation or at risk of homelessness. In Newham the local context is dire with 2,000 homeless under-fives and close to 500 children under 9’s in hotel rooms without proper cooking facilities. Conditions in temporary housing are often very poor and the impact on child development extremely damaging.
Jane Williams, Magpie CEO, underlined the consequences for child health of living in such conditions of deprivation, with delayed rolling and crawling, flat head syndrome, delayed potty training, speech and attachment disorder, lack of play, poor diet, social communication delay and increased childhood disease. A terrible litany of neglect and as her colleague Blessing observed we forget ‘we are talking about human beings’. The voice of the mums is rarely heard which leaves the Magpie Project to make sure that voice is at the heart of its work.
The mums are fearful, powerless and impoverished. This induces a state of anxiety and insecurity, physical and emotional exhaustion, without hope, facing professional indifference and institutional failure. Magpie offer a different approach:
Magpie place the person at the heart of the system which leads to a far more effective and productive process. A simple first step is a change of attitude to humanise responses.
Adopting Maslow’s hierarchy of needs Magpie show the progression from meeting basic needs, to establishing trust, creating a sense of belonging, building confidence and improving wellbeing.
As Blessing noted, the peer led partnership model is the way forward and services must be co-designed. We were reminded that this is not a natural disaster and it is not inevitable. Funders and stakeholders must invest in people and places, relinquish some control, talk to someone who has experience and share that knowledge. Above all we should be courageous in professional practice and hold those in authority to account.
London remains a place of extreme poverty and wealth. Islington People’s Rights work at the forefront of the battle against poverty. It provides independent welfare benefits and debt advice services in one of the most unequal places in the UK where 34% of older people and 27% of children live in deprived households; stark indicators of health inequality. For London around 4 in every 10 people (39%) have an income below what is needed for a minimum standard of living, 3.49 million Londoners are living in households with inadequate incomes.
THE MARMOT WAY
Professor Michael Marmot has been at the forefront of the investigation into health inequalities. These tell us a great deal about how our society functions and what we have to do to rectify the effects of inequality. The Marmot Principles provide the framework for a new approach.
Over the past twenty years life the rate of improvements to life expectancy has slowed. First as austerity bit then as Covid caused a collapse in rates of improvement. Cuts in public expenditure (falling from 42% to 35% of GDP) had inevitable consequences for public health.
Professor Marmot coined the term ‘Proportionate Universalism’ which took the standard means tested approach favoured by government and added an element of universal assistance. Combined this will include the worse off and the relatively deprived. Professor Marmot felt this was essential to achieve a true levelling up. A universalist policy proportionate to need.
During the period of austerity the biggest impact of the reductions in public spending fell on those areas of highest need. In areas of least need spending on adult social care fell by 3% but in areas of highest need by 17%. This had an inevitable consequence for rates of mortality.
A slowdown in health improvements, increase in inequality and a decline in life expectation was acerbated by the Pandemic which amplified the underlying inequalities in society, This is evident in comparing age standardise deaths and covid mortality which were greater in overcrowded households.
A study of government welfare payments show that unemployment benefits declined in value leaving people in poorer households worse off and with less income flexibility.
Universal Credit does not pay people enough to live a healthy life. The value of the benefit is only 70% of the cost of essentials, food, heat, shelter.
Professor Marmot observed that if you are dependent on Universal Credit the State has decided not to give you enough to lead a healthy life. This is compounded by the cost of living. In London where 25% live in poverty (rising to 30% if you have children), the difference in weekly income between the top and bottom deciles is 10x in London compared to 5x in the rest of the UK. The income gap is wider in London and the poor are poorer. Low income households with children are more likely to live in areas of high air pollution. London Boroughs also make up the top five worst ranked areas for pollution and child poverty. Furthermore, full time nursery places with children under two can cost a parent on minimum household income in England, nearly 2/3rds of their weekly pay. If you earn below this income level you cannot afford to go out to work.
Despite the bleak picture there is light on the horizon. There are now 40 Marmot Places established, local authorities signed up to the principles to tackle social and health inequalities, a new Health Equity Network. Businesses are signing up, to provide quality work, a living wage and good conditions and to take an active role in the community. Social justice makes for better business with a healthier and more productive workforce, and satisfied consumers and investors.
CONCLUSION
One hundred and fifty years on from the launch of the Metropolitan Hospital Sunday Fund where you live, what you do, race and social class will still significantly affect whether or not you live a full and health life. Professor Marmot’s proportionate universalism, provides a new approach and the Marmot principles, at least, offer a template to address the social determinants of health and in doing so, as the Poverty Strategy Commission suggest, begin to repair the frayed relationship between the individual and the State.
Improving trust is essential and, as the MOH discovered, this can only be done if we value local knowledge, build on evidence, and present an accessible and authoritative health message. Fundamentally, as the work of the Magpie Project demonstrates people must be placed at the heart of the process and treated with respect and kindness. Charities and civil society organisations must have the courage to challenge failing institutions. As the good Professor suggests, if the government won’t act it is for local communities to take the initiative if we are to achieve social justice and better health for all.