The recent death of Jenny Worth catapulted obituary readers back into the east London of the 1950s and ’60s. Worth had written a trilogy about her life and work there as a young midwife and staff nurse at the London Hospital. Her best known title is ‘Call the Midwife’. It is a vivid account of life, birth and death in the tenement buildings of Tower Hamlets and a reminder of the impenetrable depth of poverty in the hinterland to London’s docks. Much has changed for the better since then. The tenements have been replaced by vast estates of local authority housing, the contraceptive pill has played a key role in changing lives of the women there and Canary Warf, the new Royal London Hospital and the Olympic site dominate the skyline.
But much has remained the same – at least relatively. A King’s Fund report recently noted that ‘In London the life expectancy of the local population falls by one year with each station along the Jubilee Line between Westminster and Canning Town.’ The Health and Wellbeing Strategy of Tower Hamlets noted in 2009 that ‘Life expectancy is highest in Millwall ward in both males and females (80.2 years and 84.6 years respectively) and lowest for both in St Dunstan’s and Stepney Green (71.9 and 78.2).’ These wards are a short walk from each other. Tower Hamlets has the worst child poverty in the UK. The leader of a youth club within 182 metres (600 feet) of the heart of the City, with its bonus culture, explained in a matter-of-fact tone of voice that ‘if you are not doing well in school you go into drugs and prostitution’.
This continuing social poverty breeds a lack of aspiration and hopelessness, which in turn has a deep impact on health. Across the whole of northeast London there is a large and growing number of people who are seriously overweight and take no exercise in spite of the excitement about the 2012 Games in their midst. The population eats too much of the wrong foods, smokes and drinks too much, and diabetes is growing alarmingly. The incidence of TB, once thought to have been eliminated in the UK, is growing fast and teenage pregnancy remains a huge issue. London has the highest rate of under-18 abortions and one of the highest rates of teenage conceptions in England.
On the other hand, east London remains an extraordinarily vibrant community. It is still the main ‘arrival’ point for migrants who, together, have built London into the world’s most multicultural and diffuse city. This is now seen as a huge asset in terms of international competitiveness.
Improvement in school performance has been very marked in Tower Hamlets and Hackney recently and there is no doubt that this is beginning to lift the sights of a new younger generation, much of it in the Bengali and African Caribbean communities. However, there remain prior generations of school children untouched by this and therefore unemployed and without skills. Some 18 months ago The Equality and Human Rights Commission began to look at the NHS performance on ‘equality duties’. Their findings are deeply depressing. They say in bland language that ‘Much greater attention needs to be paid to leadership, commissioning and employment than … has been the case up to this point.’ Put more bluntly, there needs to be a revolutionary attack on health inequalities in east London and it needs to begin now and involve and include all the public sector agencies and the private and third sectors working together to a precise timetable. The Olympic Games is the catalyst.
Can this be done? The answer has to be ‘yes’ and here is how.
Firstly, the huge investment around 2012 has to be the starting gun for transformation and there are at last real signs that the public sector is beginning to understand that they have it in their hands to build east London out of 150 years of poverty. Starting with health, Sir Mark Walport, Director of the Wellcome Trust, writing recently from a patient perspective in The Times, declared that ‘All strands of health care, including primary, secondary and mental health must be integrated.’ This is a very long way from the present position. Some of the Coalition Government’s planned reforms may eventually help: there is a strong drive to re-think public sector commissioning to target individual wards and set clear and deliverable targets for commissioners working in partnership rather than in isolation. In east London there is a huge opportunity provided by the potential merger within the acute sector of Barts and the Royal London with Whipps Cross and Newham General hospitals. By delivering this and striking the right relationship with the other hospitals in east London, and with public health and social care systems moving closer together and commissioning reorganised into much larger groupings, there would be something like a single health system for northeast London. If all decisions were then genuinely to be taken in the interests of patients rather than institutions, the revolution might be started and in 2012!
The three inner east London boroughs are now blessed with able elected Mayors. This provides a further potential for cooperation across the difficult and often ill-defined administrative boundaries of social care, housing and health. Long-term poverty cannot be eliminated and attacked on all fronts at the same time. We should begin at the beginning and try to give a real life chance to those who are newborn or at pre-school age. A successful programme imported from Canada, called the Family Nurse Partnership, has been trialled in Tower Hamlets and we now need to build this across east London as part of a real Olympic legacy. It teaches parenting skills and supports new and chaotic parents throughout those difficult early years leading on to a full support system for the children through schooling and into a decent job. The latter part of the programme is supported by the Mayor’s (Boris Johnson’s) Fund for London with a number of big private sector players providing the cash.
The correlation between unemployment and bad health is well documented and it is increasingly clear that, after generations of government training provision for those on the long-term register, little has been achieved in east London. Alumni of employability schemes know that generalised training rarely leads to a decent job. Top quality training run by the public sector for known jobs in the public sector in east London would almost certainly lead to much better outcomes. It would have the added benefit of helping public sector agencies understand the needs of their local communities much better and then to angle service provision much more accurately.
Finally we need to commission our local services very differently. Most of them are emanations of politically driven programmes in Whitehall and are very blunt instruments. Poverty is very unevenly distributed at the local level as the Tower Hamlets example shows. We need to target needy wards and housing estates much more accurately and only local knowledge can do this. An alternative would be to ask the local authority, the NHS and the Metropolitan Police to define the problem and them jointly commission known local providers to deliver and assess the outcomes.
Delivered together these three programmes, including a consolidated health system for northeast London, the Family Nurse Partnership and locally targeted employment solutions, would provide a lasting legacy for east Londoners, transforming lives as well as eliminating health inequalities.