• by Professor John Ashton, President, UK Faculty of Public Health

Based on a speech given by Professor Ashton at the Active Lifestyle, Healthy Lives Conference organised by Open Forum Events Manchester, which took place on 8th October 2015 at the Manchester Conference Centre.

Regular exercise is an important part of a healthy lifestyle. People who engage in activity are more likely to live longer, healthier lives with reduced risk of developing serious life threatening conditions. And yet a recent report by the British Heart Foundation puts the UK lagging behind the rest of Europe. How can we wake up the nation to the dangers of inactivity and the benefits of exercise for health?

My good friend and mentor Professor Lowell Levin always points out that ‘the person who frames the question determines the range of solutions’. Nowhere is this more true than in the field of physical exercise. Are we talking about an active lifestyle and regular physical movement, sport and competition, physical Education and physical Culture, or ‘Muscular Christianity’? (1).

There is a recurring tension between a focus on whole population health and wellbeing, and a preoccupation with elite sport and excellence by the few. Government minister Michael Gove has spoken of ‘creating a sporting habit for life’ yet how many of us played competitive sport last weekend in contrast to those who went for a walk, rode a bike or did the garden? On occasions like this I am reminded of one iteration of the Sport for All theme in the late 1970s. Living in Hampshire at the time, as a family we were in the habit of taking the children to the swimming baths on a Sunday morning. On this particular Sunday we arrived at the sports centre to find ourselves excluded from participation by a ‘Sport for All’ demonstration by proficient swimmers! ‘Sport for All’ or ‘Sport for Some’?

With monotonous regularity we seem to oscillate between policies addressed at the many that fade when we are approaching the Commonwealth or Olympic Games, when the resources available magically disappear to be focused on the best prospects for gold medals and the nebulous hope of an ‘Olympic legacy’. And the confusion between competitive sport and a physically active citizenry goes on and on.

During the recent Conservative Party conference in Manchester, competitive sport played a prominent part in framing the political agenda  with Boris Johnson celebrating the joys of the rugby scrum. Johnson appears to have said that “our lives are a gigantic collective effort, in which one person’s bulk (mentioning no names), makes up for another person’s slightness and where everyone is so tightly bound together that one person’s forward progress drives another person”.

Meanwhile, according to the Daily Mirror, rugby legend Lawrence Dallaglio told the Conservative Party that rugby “…can build (children’s) character and give them a chance to make something of their lives”. Whilst not doubting Dallaglio’s commitment and sincerity, he appears not to have read Allyson Pollock’s recent indictment of the price the nation’s children are paying  by being forced to play the increasingly dangerous contact sport of rugby (2).

At a recent conference organised by the Epidemiology and Public Health section of the Royal Society of Medicine (3), an audience heard from speakers, many of whom were passionate rugby fans, of the crisis of concussion and injury facing a game increasingly characterised by very heavy, very fast players in life changing collisions, the association with brain damage and dementia and the increasing threat of major court action facing the viability of schools and sporting bodies.

The conference also heard that it doesn’t have to be like this and that many children, given the choice, will opt for participating in other activities that are fun and celebrate movement, friendship and the opportunity to show off a range of skills. As one speaker put it, ‘if they enjoy it they will come back’. If they did, we would be able to help them adopt a healthy lifestyle for life.

Perhaps the need for change is best summed up by a recent speech by Neil Rollings, who was a Director of Sport in HMC schools for 21 years, and is the chairman of the Professional Association of Directors of Sport at Independent Schools (4).  He told the Headmasters’ and Headmistresses’ Conference that:

“More people of my generation learned to hate team games at school than learned to love them. But there was an acceptance that sport was as democratic as North Korea. Not everyone plays team games in society. Not everyone is compelled to play team games but there are a variety of alternatives, some of which are competitive and some of which aren’t.”

He continued: “British-style independent schools are the only sporting environment in the world where participation in team games is compulsory. For over 100 years, schools have hidden some shabby provision, especially for the less able, behind compulsion and an unsubstantiated view that pain and discomfort somehow ‘makes a man of you’ through a process unknown to science.”

Meanwhile, a letter in The Times from former England rugby player Jim Roberts (1960-64), provides perspective: ‘with the current laws and levels of injury I hate to think what the current players will be like when they are 50. I would not play today’.

In this context it is worth a look at the Department for Culture, Media and Sport consultation on A New Strategy for Sport. At first sight it seems promising with endorsement and contributions from no fewer than nine government ministers. But it is soon apparent which tail is wagging the dog – it is basically about competitive sport and another missed opportunity (5).

We have a problem: sedentary living combined with an ageing population mean we have a significant burden of avoidable physical and mental ill health where an active lifestyle would make a difference. Competitive sport may have a part to play but it is probably limited and it can have serious downsides. And the spectre of the ‘Nanny State’ places limits on the ability of government to intervene on behalf of the population. Although it now seems that both the Health Secretary, Jeremy Hunt, and former Health Secretary Andy Burnham are both on the same page in agreeing that when it comes to children, nannies are legitimate. So what is needed?

My view as a public health practitioner is that we need to return to our roots and reconnect a health and wellbeing life cycle approach to town and country planning. The cliche of making the healthy choices the easy choices applies here as to much else where behaviour impacts on individual and societal wellbeing. We need to re-engineer our cities, towns, villages and neighbourhoods to make active life easy and the norm.

Walking, cycling and being out and about, gardening and allotment holding, exploring the great British outdoors: these are as much part of the fabric of British life as rugby and hockey. But importantly they can be enjoyed well past the time when compulsory school sport is a faded memory. 21st century living requires us to address this challenge with the same vigour as our predecessors dealt with the slums and urban squalor. It requires vision, leadership and a practical prism to assess all policy and development from the perspective of active life. Other countries are leading the way. Let’s not be left behind (6).


(1) Wikipedia defines Muscular Christianity as ‘ ..a Christian life of brave and cheerful physical activity especially as popularly associated with the writings of Charles Kingsley and with boys public schools of the Victorian British Empire … a Christian commitment to piety and physical health basing itself on the new testament which sanctions the concepts of character and Wellbeing’.

(2) Tackling Rugby -what every parent should know about injuries, Allyson M Pollock, Verso, London 2015.

(3) Tackling school sports injury meeting, Monday 14 September 2015, RSM

(4) Parental pressure ‘threatens team games at school’, (£), The Times, 8 October 2015.

(5) A New Strategy for Sport: Consultation Paper August 2015 Department for Culture,Media and Sport

(6) Built environment and physical activity – a briefing statement ,Faculty of Public Health, 2013

  • by Dr Tom Scanlon
  • Director of Public Health
  • Brighton & Hove City Council

They say anticipation is the better part of pleasure and I have to confess that as a kid I quite enjoyed Lent. Like a good Catholic boy, I would defer some gratification for 40 days and 40 nights; for a few years it was sweets. This worked well because I was paid in sweets for delivering a neighbour’s milk after school, gifted sweets from mum’s old school friend who came to tea every Friday, and continued to make small pocket money purchases throughout my ‘fast’.

So as Easter Sunday approached my hidden stash accumulated and my excitement escalated. Not in the spirit of things perhaps, and indeed maybe there is a God as my annual sweet fast/fest came to a tragic end when my big brother – a bit of a Hyde and Hyde character back then, stumbled across my hoard and with his mates devoured the lot – on Good Friday too. Like a bad Catholic boy, I never quite forgave him.

Of course, if Joe had been at the launch of our Sugarsmartcity initiative in early October, he would have said he did me a favour (he tried that same line all those years ago).  Althoughhough when I think back; a whole Lenten’s worth of sherbet dib dabs and cola cubes in 1969 compares very lightly with the quantities of sweets and sugary drinks we experience today, often proffered in cut price supersize at a checkout – when all you came in for was a newspaper.

We now know that sugar consumption is indelibly linked with dental caries, obesity, and in drink form to Type 2 diabetes. National guidelines have been dramatically revised down by 50%, so that just one can of coke (9 teaspoons of sugar) contains more than the recommended total daily free sugar intake for an adult (7 teaspoons).  In Brighton & Hove each year, around 25% of children leave primary school obese or overweight, and just under 300 have teeth removed in hospital, while an estimated 9.2% of our adults is diabetic; so it felt like the right time to launch a city-wide Sugarsmartcity campaign.

Just as anecdote is a powerful evidence-based tool, so serendipity is an excellent means of planning.  A public health colleague knew a chef who knew Jamie Oliver’s Campaign Director, and as ‘make connections’ is a local public health mantra, she did.  Jamie Oliver had just released Sugar Rush and as campaign directors love to campaign – Jo Ralling was more than happy to join us and has proven herself quite a driving force.  We had recently appointed a new consultant for health improvement, a fast food/restaurant public health lead, and we have a very successful public health schools programme with 95% engagement. Our Healthy Weight Partnership Board has been running for five years, so the practical and governance infrastructure was already in place, coupled with a fresh ‘appetite’ to tackle sugar.

I knew there might be some concern from local elected members about being linked to a tax (just as it appears there is nationally) so I agreed that we would run it as a public health professional campaign linked to FPH objectives, but in partnership with Jamie Oliver team. That said; our Health and Wellbeing lead publicly endorsed the work at the Health and Wellbeing Board.

After the media launch, we kicked off with a children’s public debate – at Jamie’s Italian Restaurant, chaired by the youth mayor with a panel from industry, the voluntary sector, health and education. Another debate for young people will follow shortly. We have produced and already adopted new snack and lunch policies in several schools and Jamie Oliver’s team have helped to source them free cooking and growing equipment. I co-signed a letter with Jamie Oliver, sent to over 500 local restaurants by e-mail proposing a voluntary children’s charity levy of 10p on sugar-sweetened drinks.  Independent restaurants are signing up – we’ll take stock at the end of the month.

The blitzkrieg of media – they love talk of taxes, and bans – has helped us to target the local hospital, leisure centres and school meals service. The university hospital trust is now formally reviewing their vending machine policy. The school meals provider has already revised its pudding (sugar) policy and we are optimistic that we will hear more from local supermarkets on sugar free checkouts, and leisure centres on vending.

The national debate, accusations of big business pulling government strings and manipulation of Public Health England evidence has all helped. Serendipity is one thing; but having excellent public health and communications colleagues, and a professional campaign team like Jamie Oliver’s, doesn’t half help.

I thought at the start that even if we just get our population more sugarsmart – so that people understand better what they are eating, and how it affects them and their children, that would be something.  However, we have already achieved a lot more and I know there is more to come.  It’s working well – ‘sweet’ as young people say…

  • Daniel Flecknoe DFPH
  • Bayad Abdalrahman FFPH

Imagine there is an illicit drug, which is proven to cause lifelong physical and psychological damage.  Let’s call it “W”.  People under the influence of W routinely torture or kill one another, and neglect the essential societal responsibilities which keep the rest of us clothed and fed and protected from disease.

As a result, use of W frequently results in malnutrition, deprivation and disease for non-users living in the same area, not to mention the injuries, sexual abuse and violent death which are often inflicted upon them by addicts.  Those who can leave the area will usually do so, even when the journey is perilous, and many are known to have died making the attempt, while the elderly, sick and disabled are left behind, at the mercy of the intoxicated.

Children, already disproportionately at risk from the behaviour of adult “Double-Users”, are in many parts of the world forced to take the drug themselves, leading to unimaginable developmental trauma.  As is so often the case, there are stark socioeconomic inequalities in the global distribution of negative health outcomes associated with W, with the poor suffering the worst.

Communities fractured, economic & social development retarded, millions killed and billions scarred for life (mentally and physically).  In this scenario, would it be unjustifiably paternalistic and prohibitionist to suggest, as a public health community, that W should be the subject of an intense and comprehensive prevention strategy?

Of course W isn’t really a drug, and it isn’t strictly speaking addictive (although you might sometimes wonder).  W is an analogy for warfare and armed conflict, which despite being universally acknowledged root causes of preventable morbidity and mortality still remain issues which many public health professionals feel are not within their remit to address.  Given the horrendous human cost of this phenomenon, we would argue that an urgent re-examination of our profession’s self-imposed boundaries in this matter is long overdue.

In common with a significant number of other public health professionals, both authors have spent time working in armed conflict zones trying to ameliorate the malnutrition, lack of medical care and psychological distress they generate, as well as treating some of the injuries which they directly cause.

front gate of the MSF medical facility at Shanguil Tobaya in North Darfur in 2008

Front gate of the MSF medical facility at Shanguil Tobaya in North Darfur in 2008

Although neither of us thought of it in precisely these terms at the time, we might now classify these activities as types of secondary and tertiary prevention strategies for the negative health impacts of warfare.  It seems to us that the real challenge is to promote greater public health engagement with the primary prevention of armed conflict.

This may seem like an overly ambitious goal.  The diplomatic and political catalysts of armed conflict are somewhat remote from the field of public health, even when properly recognised as major causes of preventable illness, injury and death.  They have the same elusive character as poverty, in that they are well-understood determinants of health whose levers of change exist at least partly outside of the traditional domain of medicine.  However, public health as a profession does not shy away from naming poverty as a determinant, and calling for policies to reduce its prevalence.  If the most we can do is to do the same for armed conflict then that would be better than nothing.

However, there may be other avenues by which public health professionals can extend their sphere of influence into the realm of large-scale violence prevention.  Armed conflict is both a cause and an effect of social injustice, so work undertaken to reduce inequality, whether on a local, national or international level, may also be considered to be part of a primary prevention framework.  Conflict resolution, human rights activism, democracy promotion and community integration work aimed at reducing ethnic and cultural divisions could all be part of the same framework.

International humanitarian law is also a potential tool of armed conflict prevention.  However, these laws are the product of many self-interested compromises generally made in the wake of World Wars.  This is not to discount or undervalue them, but the political will necessary first to make, and then to enforce such agreements appears only to be generated by civilization-level traumas.

While the lack of global conflicts (which directly affected the civilian populations of Western countries) in the past seventy years is something that we should celebrate, one consequence is that international humanitarian law is becoming out-dated and harder to enforce.

Recent coverage of events in the Mediterranean, the largest influx of refugees into Europe since the Second World War, has brought this issue into heart-breaking focus.  Confronted with a human crisis of such devastating proportions we propose, perhaps idealistically, a synthesis of two philosophies of assistance and advocacy:

  • Humanitarianism, which directly challenges the logic that orders, justifies or tolerates the premature death of any part of humanity in the name of some collective or national benefit, and
  • Primary prevention, which identifies the root cause of a particular cluster of negative health outcomes, inequality and human suffering, and dedicates itself to eradicating or (more realistically) substantially reducing its prevalence.

“Health through Peace” is the title of a conference taking place in November, organised by a committee of humanitarian and human rights groups, which will explore the role that healthcare professionals can play in confronting and challenging the drivers of warfare and armed conflict. Anyone interested in attending the Health Through Peace conference can read more about it and sign up here.

In the meantime, we will investigate the possibilities of forming a Special Interest Group within FPH in order to further explore the positive contribution that public health can make to the primary prevention of armed conflict.  Please email daniel.flecknoe@nhs.net if you would like to be involved in this project.

Mercy JA (2013)  “Assaultive Violence and War”. In Levy BS & Sidel VW (Eds) Social Injustice & Public health.  2nd Edition.  Oxford University Press, New York.

UNICEF (2009) Children and conflict in a changing world – Machel study 10-year strategic review.   Accessed on 15/08/2015.

Weissmann F (2004)  In the Shadow of “Just Wars”: Violence, Politics, and Humanitarian Action.  C. Hurst & Co., London.

Wiist W (2014)  Use of complex systems modelling to strengthen public health’s role in preventing war.  Medicine, Conflict and Survival.  30(3): pp. 152-164.

Public Health Response to the Refugee Crisis in Europe: why revisiting the lessons from the Kosovo Refugee Crisis in the North West in 1999 has important lessons for 2015

  • Abdul Razzaq
  • Director of Public Health, Trafford Council, and Chair North West Directors of Public Health Network

On 7 September 2015, the Prime Minister announced a significant extension of the Vulnerable Persons Relocation Scheme for Syrian refugees. The Government intends to resettle up to 20,000 refugees from Syria’s neighbouring countries over the next five years. However, it does not intend to offer resettlement to Syrian refugees already in Europe, or to participate in the EU’s proposed refugee resettlement and relocation schemes.

A joint statement from ADPH and FPH regarding the current crisis and recommendations for action can be found via here

1.    Public Health Response – Revisiting the Lessons from the Kosovo Refugee Crisis in the North West

The unstable political situation in the former Yugoslavia resulted in inter-ethnic conflict with profound economic, social and human rights consequences. It led to a major military intervention by North Atlantic Treaty Organisation (NATO) forces. A large proportion of the Kosovars were forced to abandon their homes and seek refuge in Macedonia and Albania.

The government of Macedonia was very worried that the large number of Kosovar refugees in their country might destabilise the country’s delicate political balance. This led to pressure on the European Union countries to make adequate arrangements to admit substantial number of refugees from Kosovo into the European Union countries.

The United Kingdom government agreed to take in an unspecified number of refugees. In the event 4346, refugees were admitted into the United Kingdom under the United Nations High Commission for Refugees (UNHCR) Humanitarian Evacuation Programme. Of this total 2400 were accommodated in the North West region of the United Kingdom.

2.    Kosovan Refugees: The planning in the North West Region for reception and care of refugees

The planning for the reception and care of refugees in the North West region was led by the Health Emergency Planning Advisor (HEPA). The HEPA has very close day-to-day relationship with the EPCU and reports to the Regional Director of Public Health. The HEPA is charged with the responsibility of building and maintaining the region’s capacity and capability to respond to situations that can pose a threat to public safety and health. The HEPA is supported in his work by the Regional Epidemiologist with an expertise in communicable disease control. The HEPA also has ready access to advice on environmental hazards and in addition can readily access generic public health advice.

In their day-to-day work the HEPA has established effective links with the agencies that would have a role in emergency situations. The local authorities, the health authorities, the police, the fire service, the ambulance service, the Environment Agency, and the hospital service are among the bodies with whom the HEPA has close relationships. These relationships provided the Regional Director of Public Health and EPCU with an easy and rapid access to the main agencies that have resources to meet the health and social care needs of the refugees at the local level.

The HEPA convened meetings at a sub-regional level of the key agencies to agree a basic operational framework to cater for the needs of the refugees. These meetings highlighted important issues for agencies that are charged with service commissioning and delivery.

The plan for the North West was divided into three parts or phases:

1.    Arrangements for the initial reception of the refugees at the port of entry (Manchester Airport)
2.    Arrangements to provide care for the refugees and to integrate the refugees into the social fabric of the local communities
3.    Arrangements for the safe return of the refugees to Kosovo when the conditions for return are judged to be right by the United Kingdom government and the UNHCR.

3.    Kosovan Refugees: Arrangements for the initial reception of refugees at the port of entry (Manchester Airport)

These arrangements put in place followed discussions with the key agencies with a part to play in this phase of the operation. The most immediate concern was to ensure that the medical needs of the new arrivals were attended to, taking into account the nature and urgency of the medical need.

The HEPA had established an effective communication with a Department of Health doctor who was seconded to work with the UNHCR in Macedonia. The Department of Health doctor was able to provide the HEPA with advance information about the numbers of refugees likely to arrive on the incoming flight. In addition the HEPA was also able to obtain information from the Department of Health doctor about the medical condition of the refugees on the flight.

Arrangements were put in place to provide emergency first aid assistance to the refugees once the aircraft had touched down. An ambulance was also on standby to provide safe transfer to the local hospital. The port health staff conducted the routine screening for communicable diseases. The refugees were then transported to a civic centre (situated about a mile from the airport). The arrangements for the reception of refugees at the civic centre were put in place by Manchester City Council. The arrangements were designed to:

  • Ensure that the refugees were met in warm, cheerful and friendly surroundings
  • Ensure that access to the reception was limited to those who had an agreed and defined part to play on the day
  • Meet the immediate primary health care needs of the refugees
  • Ensure that the essential formalities were conducted in a sensitive and efficient manner
  • Ensure that the initial social and housing needs were assessed
  • Ensure that the regions voluntary sector was able to make its contribution
  • Ensure that there was no media intrusion at the reception centre
  • Ensure that the refugees were transferred from the reception centre to their initial accommodation in a safe and efficient manner.

The staff and volunteers at the reception centre were briefed about the recent history of the former Yugoslavia and the origin of the conflict leading to the Kosovors of Albanian origin becoming refugees and fleeing to Macedonia for their physical safety. It was agreed that in view of the known negative experiences of the refugees of the police and the army in Kosovo, the police numbers at the reception centre would be kept to a minimum and further, that if possible the police should provide officers not in uniform for the reception centre.

The Refugee Council ensured that interpreters were available in adequate numbers at the reception centre. Manchester Health Authority provided the reception centre with the services of general practitioners registered with it. At all times there was at least one general practitioner at the reception centre to attend to the primary health care needs of the refugees. The general practitioner was supported by a nurse. The children’s needs were accommodated by the play leaders from the Manchester City Council. The refugees on arrival at the reception centre were welcomed by a senior officer from Manchester City Council.

The refugees were then provided with a hot meal on arrival before any formalities took place. The local branches of the British Red Cross played a central part welcoming the refugees at the reception centre. They brought clothes and essential toiletries for the refugees. The local and health authorities that were designated to act as hosts for refugees arriving on specified flights brought their own officers to the reception centre. These officers used this opportunity to assess the housing, social and health care needs of the refugees. They also travelled with the refugees to their initial destination.

After each completed reception operation there was a full debriefing with the aim of incorporating any important lessons into the following reception exercises.

4.    Kosovan Refugees: Arrangements to provide care for the refugees and to integrate the refugees into the social fabric of the local communities

This part of the arrangements to some extent devolved to the local partners. A number of meetings were held with the office of the Regional Director of Public Health to ensure that the variations in practice were not undesirably uneven. The key issues that needed to be tackled at this stage are discussed below:


The key tasks for the health service sector were agreed to be:

•    Help with registering with general practitioners, dentists and opticians
•    Information about the health care system
•    Awareness raising among general practitioners and hospital consultants of cultural factors, unfamiliar conditions and medical problems arising from experiences as refugees, for example, torture and other physical abuse, rape and other forms of sexual abuse, malnutrition, exposure, shrapnel and gunshot injuries and disorders relating to possible use of chemical weapons
•    Specialist provision of practitioners experienced in treated trauma related mental health problems
•    Care of pregnant women
•    Vaccinations programmes
•    Care for children
•    Advocacy and interpreting

Each health authority had an executive officer named Director of Public Health, who advises the authority of commissioning issues. The office of the Regional Director of Public Health is closely linked to the networks of the region’s Directors of Public Health. The link enabled the Regional Director of Public Health to have a degree of influence on the actions of the health authorities in this area.


The local authorities traditionally take the lead in this area. The local authorities took steps to raise awareness of the care providers in the following areas:

•    Mental health
•    Physical disabilities
•    Sensory impairments
•    Older people
•    Learning disabilities
•    Support for carers
•    Drug, alcohol misuse

The local authorities made arrangements to enable the refugees to have access to Albanian organisations in the United Kingdom and to Albanian newspapers (these were accessed via the internet).

The local authorities also made arrangements to attend to the recreational and leisure needs of the refugees. Football matches, visits to leisure centres and visits to cinemas were arranged for those who wished to take advantage of these.


The local authorities again took the lead in making this provision. The key principles were agreed with the Refugee Council. The Refugee Council was charged with approving all the accommodation offered to the refugees. Apart from the physical condition of the properties offered to the refugees the following principles were followed:

•    The allocation practices need to be flexible
•    Housing allocation needs to take account of social networks, family size and family ties
•    Refugees may need to be clustered in some areas
•    Housing arrangements should take account of the services available in the area
•    The safety of the refugees should be taken into account when an allocation is made

The local authorities made efforts to involve the refugees in the running of the reception centres and in many instances the refugees themselves took over the running of the catering arrangements.


The key issues tackled in this area were:

•    Information for parents about education in the United Kingdom
•    Access to special needs provision as defined for the general population
•    Parent/school liaison, including interpreting
•    Awareness raising and training for schools on needs of refugee children
•    Language support
•    Awareness raising for relevant agencies on needs of refugee children

A number of other related issues may need to be addressed in the future should some of the refugees remain the United Kingdom for longer than 12 months. These relate to education and training for future employment in the United Kingdom.

Kosovan Refugees:  Arrangements for the safe return of the refugees to Kosovo when the conditions for return are judged to be right by the United Kingdom government and the UNHCR

At a UNHCR meeting in Geneva on the 12 July 1999 there was general consensus among those countries who received Kosovar refugees that the return programme should be coordinated through the UNHCR and International Organisation for Migration.

The Regional Director of Public Health was instrumental in initiating a fact finding visit to Kosovo. This visit was undertaken by the team of four experienced and high ranking officials. They produced a report that was submitted to the EPCU. The team looked at the future reconstruction and development needs of the health care system in Kosovo.


1.    Syrian Refugees and the UK – House of Commons Library http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06805

2.    Syrian Refugees and the UK. House of Commons Library – Briefing Paper Number 06805, 8 September 2015. Ben Smith and Melanie Gower.

3.    Migration pressures in Europe – House of Commons Library – http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7210

4.    Balkan briefing (part 4). Kosovo refugees in the North West region of the United Kingdom. Iqbal Sram, David Ward, Journal Epidemiology Community Health 2000;54:314-317 doi:10.1136/jech.54.4.314

  • By Dr Stephen Dorey and Dr Joanna Nurse

Prevention and public health don’t actually save money, you still have to pay for another illness later on. Even if prevention does save money it takes so long to see outcomes that it’s can’t be a priority right now.

Variations on these two statements, sadly all too commonly expressed, by ministers of health and other policy makers were the drivers for a new publication by the World Health Organisation’s regional office for Europe and developed with the support of FPH. ‘The case for investing in public health ’ attempts to dispel these myths in a format accessible to decision makers.

This publication supports WHO Euro’s policy framework, Health 2020, which seeks to support a wide range of actions that can improve health. A component of Health 2020 is the European Action Plan for Strengthening Public Health Capacities and Services, which is structured around the 10 essential public health operations (EPHOs). The ‘Case for investing in public health’ specifically supports the strengthening and delivery of EPHO 8: Assuring sustainable organizational structures and financing.

Many governments have responded to the global economic crisis by reducing budgets. As the second largest area of public expenditure for most countries, health is in the financial spotlight. At the same time, there is upward pressure from the rising costs of technologies and pharmaceuticals and, to a lesser extent, from demographic changes, most notably our ageing populations. Austerity policies themselves provide an additional upward pressure from ill health associated with rising unemployment and, for those still in employment, increased job insecurity combined with wages that fail to keep pace with inflation.

This publication describes the economic and health benefits for individuals and governments of a public health approach by setting out the costs of failing to address current public health challenges. It then provides evidence of the cost–effectiveness of public health and prevention approaches across all levels of prevention including the wider determinants of health, resilience, health behaviours, risk factors, vaccination and screening. It includes the recommendations from WHO’s study of the costs of scaling up action to prevent and reduce the impact of non-communicable diseases (NCDs) and identifies those preventive interventions that show evidence for early returns on investment, not just longer-term gains.

The current costs of ill health are significant for governments in Europe: trends indicate we are headed down an unsustainable path of ever increased cost unless cost-effective policies are put in place.
•    Ageing populations with higher rates of NCDs have increased demand, while health care costs have generally increased.
•    The costs of health inequalities – the total welfare loss across 25 European countries – are estimated at 9.4% of gross domestic product or €980 billion.
•    Cardiovascular disease and cancer cost the countries of the European Union €169 billion and €124 billion respectively each year.
•    Tobacco use reduces overall national incomes by up to 3.6%.
•    Air pollution from road traffic costs the countries of the EU €25 billion, while road traffic injuries cost €153 billion each year.
•    Obesity accounts for 1–3% of total health expenditure in most countries; physical inactivity costs up to €300 per European inhabitant per year.
•    Mental illness costs the economy £110 billion per year in the United Kingdom

Some of these health costs could be avoided by shifting investment to prevent harm and increase activity in health improvement, disease prevention and health protection. Funding for public health and prevention remains a small proportion of overall health spending, despite potentially representing excellent value for money, with gains in the short and the long term, and savings for both healthcare and wider sectors of society. European governments currently spend an average of only 2.8% of their health sector budgets on prevention .

The economic justification is clear. The trend for steadily rising health and social care costs, as well as the costs of inaction, show an unsustainable situation. There is good evidence to support an expanded role for health improvement and disease prevention to increase value for money and, for some approaches, to go further and actually create a return on investments for health and other sectors, as well as potentially promoting an increase in wider economic productivity.

Many of these cost-effective interventions can also help to reduce inequalities. For example, those addressing mental health and violence prevention, which are issues disproportionately affecting population groups already suffering from adverse effects of health inequality. Investing in upstream population-based prevention is more effective at reducing health inequalities than funding more downstream approaches .

The publication provides examples of economic evidence for interventions in different areas relating to health. This illustrates the cost of inaction or “business as usual” and then outlines the cost–effectiveness of interventions. The evidence shows that a wide range of preventive approaches can be cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening.

Examples of prevention interventions that can give returns on investment within 1–2 years are provided and include the areas of: mental health promotion, violence prevention, healthy employment, road traffic injury prevention, promotion of physical activity, housing insulation as well as some vaccinations.

The evidence presented demonstrates the potential benefits of cost-effective prevention, using whole-system approaches and inter-sectoral partnership working. It shows that public health can be part of the solution. This is presented in an accessible format with short quick to read text and explanatory diagrams to encourage its use beyond the traditional public health world and help provide a tool for advocates in countries where public health may not be as strong as here in the UK.

This short video presents the key messages featuring international public health experts including a former president of FPH:


1) The case for investing in public health. Copenhagen: WHO Regional Office for Europe. 2015. (accessed 3 July 2015)
2) Health 2020: the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
3) European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
4) Scaling up action against NCDs: How much will it cost? WHO report 2011 Copenhagen: WHO Regional Office for Europe (accessed 3 July 2015).
5) Global health expenditure database. Geneva: World Health Organization (accessed 3 July 2015).
6) Orton LC et al, (2011). Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health.11:821.

  • By Dr. Trevor Hancock
  • Professor and Senior Scholar
  • School of Public Health and Social Policy
  • University of Victoria
  • British Columbia, Canada

Key points

  • We need to be more assertive in stating that public health is by far the most complex, challenging, interesting and holistic specialty in the health sector.
  • Public health is really a branch of human ecology, concerned with the health implications of the interactions of our culture and society with the built and natural environments.
  • Not only are we highly urbanised, we spend the vast majority of our time indoors, so the built environment, as a setting where the physical and the social interact, is a large factor in determining our health.
  • Nonetheless, we live 100 percent of the time within natural ecosystems on a small planet, and these natural systems – which are in decline – are the ultimate determinant of our health.

First, my sincere thanks for the honour you are bestowing on me, There is no greater honour than to be recognised by one’s peers, especially in another country, and especially by such a respected body as FPH. I have worked in public health for over 35 years, and plan to keep going until they nail down the lid of my coffin. Along the way I have learned a few things I would like to share.

Public health – the most complex specialty of all

First, health is almost entirely different from health care and medicine. While I graduated in medicine (from Bart’s), I sometimes tell medical students that I later graduated from medicine to health – and in the process, I had to un-learn medicine.

While medicine – and indeed, all the healing professions – are a noble cause, I truly believe that public health is a higher calling! Surely there are few jobs more important than keeping people healthy, protecting them from harm and preventing them from become sick or injured in the first place or dying prematurely.

Moreover – and this is something we seldom say, and not loudly enough – public health is by far the most complex, intellectually challenging and exciting of all the health professions. I like to tell medical students that by comparison with public health, neurology or heart surgery or other medical specialties are comparatively simple. Because in public health we not only need to know the biological and clinical sciences and epidemiology, we need to know ecology, urban planning, sanitary engineering, architecture, anthropology, sociology, community psychology, policy, planning, administration, communications, education, politics and more.

We need to extol the virtue of the generalist, or more precisely, the holist. Like society as a whole, we have failed to recognise that generalism or holism are in fact specialties in their own right, as are those that practice these ways of thought and action. Here I include the practitioners of family medicine as well as public health practitioners.

In fact, the multiple, complex and interacting ecological and social threats to health that we face in the 21st century cannot be solved by specialists, but by holists, who can see and recognise the patterns, understand and act on and within complex adaptive eco-social systems.

Public health as human ecology

Public health is really a subset within the discipline of human ecology – which was once wonderfully defined as “the study of the issues which lie at the interacting point of environment and culture” (Dansereau, 1966). It was the incorporation of these concepts in my work – as well as the thinking of mentors such as Harding LeRiche and John Last, who both wrote books on public health and human ecology – that led me to develop the Mandala of Health: A Model of the Human Ecososytem – together with my close friend and colleague Fran Perkins in Toronto in the early 1980s in Toronto (Hancock and Perkins, 1985; Hancock, 1985).

TGraphic of a tree, with both the branches and roots made of people,he socio-ecological approach embodied in this model has been core to all my work in public health, and should be core to the practice of public health at any level. Thus while much of my work in the past 40 years or more has been focused on the natural and built environments, it is important to understand that they both are eco-social systems.

We are now past the point at which more than half of humanity is urban, and in high and even many middle-income countries, that figure is 80 or even 90 percent. Moreover, we in the high-income countries spend about 90 percent of our time indoors. So the built environment is in many ways our most important environment.

But our cities and communities are in fact settings (as are our homes, schools, workplaces, hospitals, prisons and so on), which means they are places where the physical and the social environments intersect and interact. In fact, human ecology in part grew out of an attempt to understand cities in the 1930s. So the creation of healthy cities is an eco-social challenge.

However, while we may spend almost all of our time in built environments, we still live 100 percent of our time on the Earth, and within global and regional natural ecosystems. Those ecosystems are in trouble, and the cause is human activity. It’s not just climate change, bad though that is.

It’s also depletion of resources, especially those related to food production such as agricultural land and water; mounting damage to the oceans, which further threatens food supplies; the pollution of entire ecosystems and food chains – and ourselves – with persistent organic pollutants and heavy metals and – as result of all these and other changes – the start of a sixth great extinction, this one caused by us.

We are passing planetary boundaries for ecosystem stability in several key areas. But when ecosystems decline or collapse, so too do the communities and societies embedded within and dependent upon them.

All of these ecological changes – which are so massive and so significant that geologists are have been considering declaring a new era, the Anthropocene – constitute a massive threat to the health of the population – which means they are a public health issue, on a mammoth scale.

Public health must now adopt an eco-social approach in addressing the health implications of ecological decline (just as we did in addressing the health implications of industrialisation in the 19th century) in its task of creating a more just, sustainable and healthy future.

Public Health in the Anthropocene: Addressing the ecological determinants of health

While we have paid great attention to the social determinants of health in recent years, which I agree is important work, we have largely ignored these ecological determinants of health. That is why I have spent the past three years leading a workgroup for the Canadian Public Health Association examining the ecological determinants of health and the public health implications of global ecological change (the CPHA Discussion paper) and the 100 page technical report.

In our report we make it clear that the ecological and the social intersect and interact. The massive and rapid ecological changes we are seeing are driven by major social and economic forces which are themselves driven by social and cultural values rooted in Western notions of ‘modernization’, progress, development and growth. However, these driving forces contain within them the seeds of their own destruction. Clearly, we have to address them as a single eco-social problem.

In the 19th century, we confronted the massive challenge of industrialisation and urbanisation, and together with our reformist allies in many other sectors, we faced and largely dealt with that challenge. Of course, cities are still a challenge, especially the rapidly growing cities of the low and middle-income countries, so there is still much work to be done.

For the past 40 years the environmental movement has been doing public health’s job. Now we need to step up to the plate. We need to once again become leading players and partners in a process of reform, this time to create a more just, sustainable and healthy future for all. To do so we need to address both the urban health challenges and the global ecological changes we face.

We must educate the next generation of public health professionals in the context of human ecology and systems thinking, so they can take an eco-social approach to these massive challenges. Above all, we must become activists and advocates for economic, social, cultural and political changes that take us away from our present unhealthy course and that help steer us towards the more just, sustainable and healthy future we must create for future generations.

That is my challenge to the public health profession and to FPH. I hope you take it up.


Dansereau, P. (1966) 1st Commonwealth Human Ecology Council Conference, London.
Hancock, Trevor (1985) The mandala of health: a model of the human ecosystem Family and Community Health 8(3): 1-10.
Hancock, Trevor and Perkins, Fran (1985) The mandala of health: a conceptual model and teaching tool Health Education 24(1): 8-10.

  • by Ben Barr Senior Clinical Lecturer in Applied Public Health Research, and David Taylor Robinson Senior Clinical Lecturer in Public Health Research
  • Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool

The chancellor has committed to the NHS plan, which says “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”

Yet his announcement of a £200 million cut in public health funding, contradicts that statement and puts the NHS plan at risk. This 6.2% reduction in the public health budget will have adverse consequences for the health and wellbeing of the communities served, as well as increasing future demands on the NHS. Many public health services are cost saving, meaning that this action is likely to cost the Treasury much more than £200 million in the long run (1).

But will all areas be affected equally? This will depend on where the cuts fall, with the harm caused proportional to the absolute reduction in resources in each area. The £200 million cut is the equivalent to a reduction of just under £4 per person in England. Quality Adjusted Life Year (QALYs) (1) are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality of life score. A cautious estimate of the cost effectiveness of public health interventions is £633 per QALY gained, which would indicate a potential reduction of 600 QALYs per 100,000 population or 32,000 QALYS in total. Previous austerity measures, in particular cuts to local authority funding, have not been applied equally, but have hit the poorest hardest (2). Public Health England is to consult with local authorities on how these new cuts will be implemented and it remains to be seen where the axe will fall.

Graph final

Figure 1 shows the likely impact of three possible scenarios for distributing the public health budget cuts across local authorities (LA):

1. a flat cut of 6.2% to each LA;
2. a Pace of Change (PoC) policy with the percentage cut distributed according to each LA’s distance from their target allocation in the PH allocation formula , and
3. a needs weighted cut, with the absolute cut in funds in each LA, inversely proportional to the level of need in that local authority. For example, an LA with twice the average level of need, as measured in the PH allocation formula, would receive half the average cut.

The effect of these three scenarios is shown for all local authorities, divided into five groups, from the most deprived 20% to the most affluent 20%, both in terms of the absolute cut in resources per head of population and how that translates into QALYs lost, assuming an average cost effectiveness of public health interventions of £633 per QALY.

The flat cut and PoC scenarios clearly have the potential to increase health inequalities. A flat 6.2% cut to all local authorities would have a greater adverse impact in poorer parts of the country. Somewhere like Blackpool BC would lose £9 per head of population, whilst Surrey CC would only lose £1.70 per person.

A Pace of Change model would have an even greater adverse impact on poorer areas. As more deprived local authorities are more likely to be over target, poorer areas would receive an even greater cut in funding in this scenario. Blackpool BC would lose £19 per head of population, whilst Surrey would lose only 70p per person. This would come on top of larger cuts in core local authority budgets that have already occurred in these areas, with Blackpool BC having lost £225 per head from its core budget since 2010, whilst Surrey CC’s budget has only been reduced by £53 per head (3).

There is evidence that each pound of public health investment results in larger health gains in deprived populations (4) and therefore each pound cut may have a even greater adverse impact in more disadvantaged areas. If that were the case this analysis would under-estimate the overall adverse impact of these funding scenarios on health inequalities.

The needs weighted option is unlikely to increase health inequalities. In this third scenario, since the level of cut in each LA was weighted by the level of need, the cut is lowest in the deprived local authorities that have the highest needs. In practice any policy that results in a higher absolute cut in resources from poorer areas as compared to more affluent areas is likely to increase health inequalities.

Cutting public health funding is likely to damage people’s health, increase demand on the NHS and cost more in the long run. But if these cuts fall hardest on the poorest parts of the country they are also likely to widen health inequalities. We already have some of the largest differences in health between regions, of any country in Europe. These result from and contribute to the massive economic divide between the richest and poorest parts of the country (5). Reducing rather than increasing these inequalities is not only a matter of social justice, but will also be necessary for the government to achieve its aim of rebalancing the economy.

References and further information

PoC policy assumes the minimum cut is set at 3% and the maximum cut rate is set at 15%. The local authorities that are most under target get the minimum cut of 3% and those most over target get the maximum cut of 15%. A number of local authorities who are relatively over target, but not the most over  target, receive a cut above 3% but under 15% depending on their position from target relative to all other local authorities.

Other references:

(1) Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Public Health 2012; 34: 37–45.
(2) Whitehead M, McInroy, N, Bambra C, et al. Due North Report of the Inquiry on Health Equity in the North. Liverpool: University of Liverpool and the Centre for Economic Strategies, 2014.
(3) Local Government Finance Settlement 2014-15 and 2015-16. .
(4) Barr B, Bambra C, Whitehead M. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014; 348: g3231–g3231.
(5) Bambra C, Barr B, Milne E. North and South: addressing the English health divide. J Public Health 2014; 36: 183–6.


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