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  • 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 7.4% 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 illustrating impact of cuts

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 7.4% 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 7.4% 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.

  • By Neil Squires
  • Chair of FPH’s International Committee – soon to be renamed the Global Health Commmittee

There was a real buzz about Global Health in the Faculty of Public Health when I chaired a meeting of the International Committee on the 1st of June. The Faculty Board has approved a five-year Global Health Strategy (2015-2020), which will be launched in the pre-conference session on 23rd June, at the annual FPH Conference in Gateshead.

A survey of FPH members in 2014 highlighted that the majority of Faculty Members are interested in and commitment to supporting FPH’s engagement in Global Health, prompting a period of intensive work by the International Committee  to develop the strategy.

The benefits of thinking globally and acting locally to improve the public’s health have long been recognised, but the mutual benefits of supporting global action on health to protect health abroad and at home have never been more apparent than during the fight against Ebola.

The Global Health agenda is not new. It was recognised in the Department of Health’s, Health is Global outcomes framework for global health (2011-1015) that investment in Global Health is needed. Public Health England responded to the challenge in 2014, with the launch of its Global Health Strategy (2014-2019), setting out priorities for action.  But 2015, the target year for achieving the Millennium Development Goals (MDGs), is the milestone year in which FPH will launch its strategy.  The Strategy is an affirmation of the FPH’s commitment to Global Health and the Conference launch could not have been better timed.

Much of my public health career, before moving to Public Health England in 2014 and taking up the chair of the International Committee this year, has been spent working on global health for the Department for International Development (DFID).The priorities for global health which shaped UK international health priorities over the last 15 years have, in large part, been framed by the eight Millennium Development Goals, thee of which (MDGs 4, 5 and 6) focused directly on health.

The next 15 years, will see a shift in focus to the Sustainable Development Goals (SDGs), a much broader set of goals intended to be relevant to all countries, not just the poorest. The SDGs have just one health specific goal, but under this sit a broad range of health targets and indicators.

The health related targets aim to build on progress achieved against communicable diseases and add the rising burden of non-communicable disease, addressing health system challenges and working beyond the health sector to address the broader determinants of health to list of priorities.  The arguments put forward for including a target on universal health coverage in debates on the SDGs have been a very clear attempt to address inequality, which remains a major challenge to global health.

In developing the FPH Global Health Strategy, the priority was to identify the comparative strengths of thFPH and its membership, and address FPH’s strategic goal ‘to actively contribute to the improvement of global public health, through the organised efforts of FPH members’.

The strategy is built around a set of four core functions of FPH: advocacy, standards, building  workforce capacity, and knowledge, which are set out below.

Text summary of FPH's global strategy
Summary of four key functions of FPH

The strategy will be delivered through a number of Special Interest Groups (SIGs), which will be meeting in Gateshead on the morning of the 23rd, immediately after the launch of the Strategy. Special Interest Groups for Africa, India and Pakistan are all looking to recruit new members, and identify anyone with an interest in, and willingness to commit time to supporting action. Each group will be agreeing clear terms of reference and seeking to map current activities against the strategic priority areas set out in the Strategy.

If FPH is to have an impact at the global level, then it will be important to focus its activities on a limited set of priorities where there is a real potential to leverage action and change. Exciting opportunities to engage FPH members in India, Pakistan and in various countries in Africa are already being developed.

Other key news linked to the Board approval of the Strategy was agreement that the International Committee will change its name to the Global Health Committee (GHC).  The GHC will also be reaching out to other Royal Colleges in order to build support for more coordinated action on global health by taking on the chair of International Forum of the Academy of Medical Royal Colleges.

Again, a name change is proposed, with the hope that the Forum will become the Global Health Action Forum making real progress to coordinate approaches and work together on a range of global health issues.

So, the Global Health buzz is growing louder and I hope that rising levels of energy and enthusiasm generated developing the Strategy will galvanise Members with an interest to engage in one of the SIGs and help ratchet up FPH capacity to contribute effectively to improving global health.

  • by Catherine Max
  • Independent consultant specialising in sustainable health and social care

Catherine Max attended “Is a ‘postcode lottery’ in health ever justified?”, a panel debate hosted by the Nuffield Trust and Royal College of Surgeons on 19th February 2015.  You can see information about all the speakers and watch the webcast here.

I attended “Is a postcode lottery in health justified?” because of my interests in health inequalities, sustainable development and ethics, as well as experience in a prior PCT non-executive role dealing with Individual Funding/Exceptional Treatment requests.  As I tentatively raised my hand, I was shocked to find myself the only person at the Nuffield Trust/Royal College of Surgeons #NHSRationing debate claiming to represent public health (I have no formal qualifications as such).

But I was also struck, in a positive sense, that it was a GP asking whether public health was in the room.  Dr David Jenner, Chair of the Eastern and Mid Locality of North Eastern and Western Devon CCG was rather brave, I thought.

Not only was he willing to admit to the realities of local variation in treatment on offer (including between individual GPs in the same practice), he was happy to remind an audience of clinicians and special interest groups that it is housing and employment that reduces health inequalities. Not, that is, a nationally standard menu of treatments for those who are already ill nor a funding allocation designed to meet the health needs of the current crop of over 65s.

This last thought was echoed by Nigel Edwards, the Nuffield Trust’s Chief Executive, who reflected that it is both a value judgement and a political calculation whether to incorporate funding for unknown, non-voting future generations into the NHS budget distribution.

Decisions can only be made on an objective and scientific basis up to a point, as they embody societal and personal values which are often fundamentally irreconcilable … Trade-offs and compromises are inevitable…

Edwards N. Crump H. and Dayan M., ‘Rationing in the NHS‘. Nuffield Trust Policy Briefing #2.  February 2015.

The event began with a presentation by Ben Page of IpsosMORI. His research exposes the inconsistencies the British public are willing to tolerate and the inequalities that result. That includes you and me, lest we are tempted to feel smug. Overwhelmingly, we lack trust in central institutions, with a whopping 79% of us trusting local government instead to make decisions about local services.

But this view sits in tension with a three to one preference for a uniform offer in health as well as the distinctively high value we place on the NHS as a national institution.  It’s what makes us proud to be British, apparently, more so than the royal family and our system of democracy. We justify this preference in terms of the slippery concept of ‘fairness’, which, of course, means different things to different people. Are we talking about equality of access here or ‘each according to their need’?

As Nigel Edwards pointed out, we are also beset by a path dependency problem:  where we are now in terms of health provision is shaped by history and that’s not something we can ever completely escape. Everyone on the panel agreed that governments of all stripes fail to face up to these inconsistencies because they want to avoid the tough decisions about funding and access that would otherwise result.  The political fudge that is the Cancer Drugs Fund is a case in point.  Dr Jenner made an admirable but unlikely plea for more political certainty. Leadership, in other words. No fans of the CDF either (see Helen Crump’s blog here), the Nuffield Trust’s take on the issue is nevertheless more pragmatic.

Their Rationing in the NHS pre-election briefing calls for greater transparency and rigour in decision-making, and moots an enhanced role for NICE whose technology appraisal methodology is internationally admired. Personally, I’m inclined to say that transparency and consistency are necessary but not sufficient for ‘fairness’, and the local NHS accountability lacuna left by the Health and Social Act 2012 continues to trouble me.

In that spirit, I welcome the opportunity presented by the decision to devolve the £6bn NHS budget to Greater Manchester. But if we want local, responsive and democratically legitimated services, then inconsistency may well be the price we have to pay. If ‘fairness’ is the goal, then what’s needed are upstream interventions to reduce inequality of need in the first place. A panel of clinicians, pundits and a former government Minister had the humility to acknowledge that, and I salute them for it.

The following article has been written by Dr John Middleton, Vice President for Policy for the UK Faculty of Public Health. It has been written in response to many members’ requests for information and support when confronted with organisational changes following their transfer into local authorities. The views expressed are those of Dr Middleton and as he says in the article, the comment cannot be taken as legally watertight. FPH will not be held legally responsible for any matters arising from individuals or organisations acting on points made in this article. Many authorities may take a different view or have received different legal opinion.  There is no substitute for our members being directly advised by a recognised trade union and through them, accessing expert legal opinion. FPH will not be held legally responsible for any matters arising from individuals or organisations acting on points made in this article.Some members have found this article helpful and for this reason we are now publishing it on FPH’s blog, as a companion piece to the Job Evaluation advice produced by the Public Health Medical Consultative Committee.


Public health reorganisation: employment issues observations from a former DPH on moving and reorganizing staff in a local authority. A growing number of councils are now seeking to change their public health staff that transferred from the NHS on to council terms and conditions of service (TCS). FPH is increasingly receiving concerns from our members about this. The questions tend to come in my direction because of my experiences reorganising public health in Sandwell before I retired in March 2014. I have finally managed to put this down on paper. Hopefully this will be of help to people in this painful and difficult predicament. They are my thoughts and views and not necessarily legally correct. So there is no substitute for getting your own advice and making sure you and all your staff are members of appropriate trade unions who can represent you.

What is the real legal position of public health staff following their transfer from PCTs to local authorities?   There are a number of terms which feature in the law, in the status of public health staff in local authorities and in the change of employment and reorganisation processes. Among these provisions and terms are:

1. TUPE – the Transfer of Undertakings (Protection of Employment) regulations 2006. If an undertaking transfers from one employer to another, public or private, the new employer is obliged to honour the TCS of the staff who transfer with it, for as long as the staff are doing the same job.

2. Transfer order – the formal letter to local authorities from the Department of Health, on behalf of the Secretary of State, notifying them of the public health duties were described as a ‘transfer order’. It only guaranteed protection for NHS TCS until April 2015.

3. Equal value – Councils are exercised by the case law around equal value. The most well known is the case won by Birmingham city council cleaners (mainly women) that their work should be regarded as of equal value to refuse collectors  (mainly men). Councils fear that other groups of their staff will bring forward claims of equal value to those of transferring public health staff and make legal claims to be put on the same value terms and conditions. Strictly speaking they could only do this if they are in the protected characteristics under the Equality Act – e.g. female or of an ethnic minority. Some councils will say it is difficult to predict where the claims might emanate from. It could be suggested that as public health is a more female oriented workforce with a higher proportion of BME workers, such claims might be less likely to succeed. Within the Equal Value considerations there is the term: a good material defence. The fact that there is a quasi-legal transfer order telling councils to take on public health staff on NHS terms provides in legal terms a ‘good material defence’ against equal value claims. But the power of this defence diminishes over time, the argument being that councils should take steps to promote equality in workforce terms and conditions. Where they know there are differences, they should take steps to eliminate these. Those equal value claims therefore could start to appear shortly after April 2015. In the case of Sandwell Council, they were quite clear that by April 2015, they wished to have this risk eliminated. The reorganisation was planned to be in place by the end of March 2014, with staff on protected TCS for a year, until April 2015. In practice there was slippage in the consultation period by 2 months, but the reorganisation went through.

A TUPE transfer or a TUPE like transfer? The Transfer Order has been described as ‘TUPE-like transfer’. The BMA (and Unite the Union) take the view that whatever the legal niceties are about the transfer order, it is a TUPE transfer.  As long as staff are doing the job they were doing in the NHS TUPE applies to them, indefinitely. The other important consideration stressed by the BMA is that it is the transfer of a health service to local authorities. The same functions that were the responsibility of primary care trusts in the National Health Service are now local authority responsibilities. It is not the transfer of a public administration function, which councils can claim they can deliver in any way they choose. This could be of crucial importance should unions representing public health staff comes together to mount a legal challenge for TUPE rights to be preserved. Even under TUPE councils do have the right to make changes to TCS. But to be able to do so they must be able to demonstrate they have and economic, technical or organisational (‘ETO’) reason for doing so. It can be all or one of these:

  • ‘Economic’ might be to make savings, but is difficult to justify given that sufficient budgets should have come over to cover existing staff through the ring fenced budget.
  • ‘Technical’ might apply if someone says the department needs more of one kind of professional expertise and less of another.
  • ‘Organisational’ might be changes under economic and technical or might apply if there were other council structural changes.

Consulting on reorganising If a council has an ETO justification, they have to present a new organisational structure, new job descriptions and personal specifications, have undertaken job evaluation under the NJC or Hay systems and consult staff informally and formally. Formal consultation ideally is 90 days; they can do it in 30 and pragmatically in a small department it might be 45 days, but that is not sound practice.

During the consultation all staff are placed at risk. There has to be a challenge period within the consultation in which staff has the right to present their evidence that shows that a job in the new structure is what they are doing. If they can show they are doing 70% of the new role (as a rule of thumb) it is likely to be their job and if they win their challenge they are no longer at risk and stay in the new structure on their NHS TCS. But if they are no longer at risk they cannot then apply for posts, which might be more favourable in the new structure (until all internal appointment processes have been exhausted and the posts are advertised externally).

For some very senior staff particularly it may be very difficult for a council to say they are not doing the same job. A council cannot simply overnight tell you are on council TCS, unless they are willing to risk unfair dismissal or constructive dismissal claims. One unpleasant side effect of all this is the complete demoralisation of staff who have been doing a competent job. In the consultation document, they will have seen that their posts have been deleted. They are at risk. At the end of consultation they have to apply for their new jobs, unless their challenge has been successful.

Some staff may be so dispirited they want redundancy. Again, rules of thumb are that if a post represents a 15% cut in salary it is not the same post and therefore is a redundancy discussion. To be successful in redundancy staff will also want to show the post does represent less than 70% of their old job. They may request redundancy simply to ensure they go out on NHS redundancy terms.

Other staff may make a personal judgment to take a new job, knowing they have a year’s protected salary but knowing they are not going to stick around to see it gone and looking for external posts under NHS continuity of service – PHE, CCG or increasingly, NHS England. All of these choices are painful, processes are often ugly, dilemmas and contradictions emerge, for staff and managers.

All staff has to treat each stage as a serious application for the new positions. For managers this can be difficult when you know what your members of staff are capable of but they don’t show it at internal interview. There is no obligation on the employer simply to take the at-risk people into vacant posts, or to put people into posts where they are the sole candidate.  At the end of the first wave internal recruitment, any remaining vacancies have to be advertised internally, to at risk staff within the council. If there are still vacancies after this then they can go to external advert. At this point internal public health staff can have a crack at jobs that look better than the one they have taken or which they won their challenge on.

For some junior staff the reorganisation may present better opportunities – for example admin and clerical staff may have some more favourable TCS from the council, for example, more holiday.  For posts below A&C 7 there may be less damage to the member of staff. AFC grades over 7 have more extended pay bandings than NJC grades so a change of terms and conditions is likely to become more detrimental.  For AFC 8b upwards, staff really start to lose out. In Sandwell, the highest NJC grade J was a maximum of 49k compared to 56k for top of AFC 8B.  8C staff could only be protected if they can be moved to Hay grades. (In Sandwell,  £54-67K in 2013-14.


The lessons of all this are: – You did transfer under TUPE. – So far, unions have not taken forward serious legal challenge on this. – Your council can change your terms and conditions if they change your job, but they cannot do so without an economic, technical or organisation (ETO) reason on which they must consult you.  There must be a new structure, new evaluated job descriptions and personal specifications, and an opportunity to challenge. – For your own protection, for God’s sake join a union. If your representative isn’t sufficiently familiar with the work we do, ask for another representative and if necessary, a regional rep. – Your council cannot just send you a letter with altered TCS and altered salary.


Job evaluation   I have also been asked to share what I know about council job evaluation schemes. It is a dark art and an esoteric operation. Hay grading seems particularly shrouded in secrecy, pay walls and heavy copyright enforcement. Which is all utterly contrary to transparency in the public sector and needs to be blown open using the Freedom of Information Act.

National Joint Council oversees all employer trade union negotiations.  NJC TCS cover most council staff in grades from A to J.  The level of pay against these grades in Sandwell in 2013-14 was 16k-49k maximum point in J. / Hay grades 54k- 67k tend to be used for senior managers below director.  It is of note that NJC is not recognised by about 40 councils so it is as well to check what your own council’s position is on this. Job evaluations comprise 13 job factors as shown in the table from the NJC handbook, THE GREEN BOOK, Page 136 PART 4.1, APPENDIX.  

The job factors are assessed by job evaluators against job descriptions and personal specifications but the ‘Gauge’ questionnaire is a precise route of questions in a handbook, and the course of answering them eventually arrives at a final one beyond which the assessment of the factor goes no higher. This is called the ‘job trace’. Councils protect their job evaluators to do this work.  They try to ensure their impartiality and cushion them from the influence of managers who want to big up their staff, from trade unions and staff themselves. But it is not a precise art and it is helpful for directors of public health and managers to know something about the process of job evaluation, to understand how local interpretation of job factors is done (and yes, to get new staff in at the highest possible council grades).

Hay Grading is an extremely clandestine process, there are few licensed/approved evaluators operating from Local Government Employers at regional level and in some councils. The software and even the policy and processes are jealously guarded intellectual property, behind a pay wall.

Contrary to popular perception, job evaluation in councils is not stacked towards holding big budgets and managing lots of staff. In the NJC Green Book, The Knowledge factor scores up to 163 points, double the highest score for financial business. Initiative and Influencing also scores over 100 and demonstrating influencing work beyond the council also scores highly. You must get your council to formally recognise that public health is a whole service area. This carries a specific meaning for the job evaluators. It is generally agreed in the joint staff committee but the chief executive can decide it.

I had always taken for granted that public health was a ‘whole service area’ because of the wide range of council activities we are involved with and influence. However, it carries a very specific meaning in job evaluation and job evaluators will not be able to answer key questions in the job trace favourably if PH is not seen as a whole service area.

The joint British Medical Association and Faculty of Public Health guidance on job evaluation for public health specialists seeks to dig into these issues in more depth. However, it is a world in which there is much secrecy, much that is esoteric, and much that is hidden. It is as well to get alongside your human resources colleagues and try to understand just how the process works in your local authority. Don’t let it just happen to you or your department. Even if the outcome is not what you want, it is necessary to challenge, to try to understand and to persuade and try to get the best outcome for you, your colleagues, for the council and for the people we serve.

  • by Dr Yvonne Doyle
  • Regional Director, Public Health England

London has a vision for health and there is some exciting work going on to address the city’s health problems. On the global stage, London is falling behind; it is ranked seven out of 1 comparable cities around the world in terms of health, wealth and education. This isn’t good enough. We have an aspiration to be the world’s healthiest major global city and must improve the lives of Londoners if we are going to be a competitive city in the future. We want London to thrive. We want to attract people to live here, grow old here and to experience a good quality of life.

PHE London welcomed the publication in October 2014 of the London Health Commission’s report Better Health for London. The Commission was chaired by Lord Ara Darzi and the resulting report made a number of recommendations to the Mayor which describe how health and health care could be transformed in London. The vision set out by the report centres on ten aspirations that could, with the engagement of key stakeholders, help galvanise action across the capital to significantly improve the health of Londoners.

PHE London was able to play a role in the work of the Commission. I led the “healthier lives, tackling health inequalities” expert group and learnt a lot during the process about Londoners, their aspirations and the tremendous insights, innovation and energy that exists in different places and ways across London. This experience has made me confident that, if taken forward in the right way, the health of Londoners can indeed be transformed.

The focus of the report on improving the health of Londoners, and the need to reduce the deep inequalities in health that are evident in the city, was particularly welcome. Aspirations to create a city where every child has the best start in life, they grow up healthy, and that adults are supported to remain in good physical and mental health, are ones shared with PHE. The aspiration to reduce the large gap in the health experience of some of the population, particularly those with severe mental health problems, also has our support.

The Mayor has now published his response to the London Health Commission and agrees that the aspirations are the right ones. He will ‘personally chair a group and prepare a unified delivery plan’ for the report (one of the recommendations), therefore continuing to act as chair for a refocused London Health Board which will oversee delivery of the report’s aspirations.

This new iteration of the London Health Board met on 12 March and had representation from key health partners in London including London Boroughs, NHS England and myself for PHE London. It will now focus on progressing improvements in health, health inequalities and making the case for the investment London needs in health and care services and the wider determinants of health. The main agenda item was defining the “next steps” that need to happen to help London achieve its ambitions. It was agreed that we have to be clear about exactly what we want to achieve and the only way we will succeed is by working collaboratively. If we share good practice and take an innovative approach, then I think we can do this.

The London Health Commission report makes wide ranging recommendations. Each are worthy of further debate and discussion regarding whether they are the right thing to do in the right way at this moment in time. PHE will play its part, bringing health intelligence and expertise to bear, while others will create policy or deliver health improvement services. However, we do recognise that in many of the areas identified we have a role to play in advocating action, helping to galvanise our collective endeavours and supporting those who do have a delivery function.

My team and I in PHE London are an asset for London; this is what we set out to do back in 2013 when PHE was formed and our purchase on this continues to grow. We are here for London and we’ll do our very best to work with anybody who wants to come forward and open new doors for us.

10 aspirations for London:

1. Give all London’s children a healthy, happy start to life.
2. Get London fitter, with better food, more exercise and healthier living.
3. Make work a healthy place to be in London.
4. Help Londoners to kick unhealthy habits.
5. Care for the most mentally ill in London so they live longer, healthier lives.
6. Enable Londoners to do more to look after themselves.
7. Ensure that every Londoner is able to see a GP when they need to at a time that suits them.
8. Create the best health and care services of any world city, throughout London and on every day.
9. Fully engage and involve Londoners in the future health of their city.
10. Put London at the centre of the global revolution in digital health.

London’s health:
• 1.2 million Londoners smoke, killing 8,000 people a year. 67 London schoolchildren start smoking every day, inspired by the adults that they see.
• Half of all adults in London – 3.8 million people – are obese or overweight. London now has more obese and overweight people than New York, Sydney, Sao Paolo, Madrid, Toronto, and Paris.
• London has the highest rate of obese or overweight schoolchildren of any peer city in the world. By the end of primary school, nearly a third of children are obese or overweight.
• Just 13% of Londoners walk or cycle to work or school. This is despite around half living close to their schools or workplaces.
• Pollution is killing 4,200 Londoners a year: 7% of deaths in the capital are directly related to poor air quality.
• London employers are losing £1.1 billion from sickness absence due to stress, anxiety and depression.
• Nearly 500,000 hospital admissions are related to excessive alcohol consumption. Problem drinking is particularly acute in a small number of London boroughs putting big strains on the NHS.

by David Pencheon, FPH member

This blog is part of a series of posts to promote discussion and debate around the priorities in Start Well, Live Better: FPH’s manifesto for the 2015 General Election.

"Never in human history has the health and welfare of so many people (already living and yet to be born) depended on so few people who know so much and are doing so little."

Our behaviour is more influenced by our surroundings than we think.  Our behaviours are a function of what surrounds us – physically, socially and culturally,  We are shaped by norms more than we shape them.  Consequently, when an influential group of people have the chance to re-set norms in visible and newsworthy ways, where results benefit almost everyone both immediately and long term, why wouldn’t we seize the opportunity?

Well, health professionals and health organisations now have such a chance.  The case for divesting from fossil fuel is now very strong.  The British Medical Association (BMA) is committed to this journey and since its 2014 Annual Representatives Meeting (ARM) is actively investigating how best to send out a powerful message on health and social justice.

This very welcome move will hopefully start a trickle and then a tidal wave of divestment from the fossil fuel industry which, like the tobacco world, has spent outrageous sums of money on sowing doubt about the harmful effects of a high carbon world and the beneficial health and equity effects of a low carbon society. Read Oreskes book: Merchants of Doubt.

In retrospect, the data now strongly suggest that the fall in smoking levels amongst many groups did not really happen until health professionals (particularly doctors) stopped smoking.  We all have bizarre habits where our creative energy is used more to justify them than to address them.  If we struggle to justify our smoking habit to our peers or to ourselves, where better to reassure one’s self than by pointing to a health professional smoking.

Change does happen though, often quickly, although rarely planned (witness the banning of smoking on the London Underground).  Such changes are often not driven primarily by the law (smoking on planes and overground trains).  If health professionals and organisations simply all say: no, we do not invest any assets we have supporting an industry which knowingly perpetuates an addiction (to fossil fuel) and does not actively attempt to address this threat in the radical ways needed.

Fossil fuel companies need to understand that their so called wealth is largely based on resources still in the ground – which the incontrovertible evidence (supported by the UN, the World Bank; The Pentagon, the UK Ministry of Defence, and the CIA) says needs to be left there.  City investors are already having doubts about the real worth of some fossil fuel companies if their so-called assets are theoretical.

We should therefore welcome the move of the BMA to be the first large health organisation to tread this path.  A full description of the background to why we should actively divest from the fossil fuel industry is in MedAct’s latest report. What we will do in future might appear odd and different now, but in retrospect nearly always appears normal surprisingly quickly
We have a duty and responsibility to help shape the future as much as we are shaped by it.

The great mystery to historians at the end of the 21st century (if there is anyone left to write our history) any of us left) is why, at the beginning of the century, we did so much talking and research on what is happening and took so little action.  Never in human history has the health and welfare of so many people (already living and yet to be born) depended on so few people who know so much and are doing so little.  Do something good today and write a letter to the President, CEO, Chair and Treasurer of the BMA and congratulate them for at least actively and publicly committing themselves to this journey.

And ask your own organisation how much is invested in the fossil fuel industry. These are not easy questions. What constitutes a fossil fuel company? Are any savings I have ethically invested? But they are not impossible. We must not let perfection be the enemy of pragmatism and we must start today not tomorrow.  This is all happening on our watch and will be our legacy.

When our great grandchildren say to us: what did you do at the beginning of the century, let us all try and do more than just mumble we that we knowingly and passively conspired with circumstance. Health professionals, rightly or wrongly, are still well respected, are numerous and interact with all members of society every day and in every community in the land.

Numbers matter: one person is a crackpot, two is a pressure group, and three is a social and political movement. If health professionals don’t draw a line in the sand, then who will? And if we don’t do it now, then when will we do it?

Further reading:
1.    Oreskes and Conway: Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming.  2013.
2.    MEDACT’s call for Fossil Fuel Divestment by the Health Sector. “Unhealthy Investments”
3.    BMJ 2014;348:g2407  Why doctors and their organisations must help tackle climate change: an essay by Eric Chivian
4.    The Faculty of Public Health “Sustaining a Healthy Future – taking action on climate change” 2009
5.    The Global Climate and Health Alliance Civil Society Call To Action at the World Health Organisation Conference on Health and Climate August 2014

A version of this blog was first published on the BMJ website.

I am a child. During the next 15 years I am likely to: Question my body image. Make my first independent decision about my diet and exercise. Witness or experience bullying. Have my first sexual experience. Be offered a cigarette. Be offered my first taste of alcohol. Make my first decision about drug use. So, asks the PSHE Association, ‘Who is going to teach the knowledge and skills I will need to manage these ‘first moments’ and stay healthy and safe? (1)

  • By Marie Findlay, Policy Team, Royal Society for Public Health

Around 9% of teenagers in England are regular smokers by the age of 15 (2) and in the last month in the UK, more than half of 15-16 year-olds consumed five alcoholic drinks (3).  Teenage pregnancy rates are among the highest in Europe (4) while 31% of young men and 37% of young women aged 11-18 are overweight or obese  and only a minority do the recommended amount of physical activity (6).

Over half of mental health problems develop in teenage years (7). The significance of adolescence in forming behaviours that impact on health over a lifetime can hardly be overstated, and yet the health outcomes of young people in some of our communities are among the worst in the developed world (8).

Eight Young Health Champions recieve an award from Duncan Selbie

RSPH Chief Executive Shirley Cramer, CBE, (left) joins children from Manningtree High School. They were the first graduates to be awarded the RSPH Level 2 Certificate for Youth Health Champions (YHC) by Duncan Selbie (centre), at a ceremony attended by Jane Davis (right of Ducan Selbie), YHC Coordinator at Manningtree High School. 

Schools are unique, being one of the only agencies that have regular contact with almost all children and young people during these formative years. It is therefore essential we utilise this opportunity to properly integrate health education in order to equip everyone with the knowledge, understanding and skills to navigate a complex world of choices and lead healthy, fulfilling lives.

Personal, Social, Health and Economic education (PSHE), highlighted by the Chief Medical Officer as a ‘bridge’ between education and public health (9), not only provides this opportunity but can also drive improvements in a range of Public Health Framework Outcome indicators (10).  Young people themselves are hungry to learn, with 86% of pupils feeling they need to be taught about PSHE topics in school.  Why, then, does PSHE remain a non-statutory part of our children’s education?

Perhaps the issue is masked by the fact that most schools deliver elements of PSHE in some form. But while curriculum requirements entail coverage of some components, quality of provision is hugely variable (12) and the 2012 Ofsted Report concluded that it was not yet good enough in a sizeable proportion of schools (13). This leaves many children and young people vulnerable with gaps in knowledge and skills spanning relationships, mental health and alcohol misuse (14).

Following the latest review, Elizabeth Truss, then Parliamentary Under Secretary of State for Education and Childcare, deemed a change of status unnecessary as ‘Teachers are best placed to understand the needs of their pupils and do not need additional central prescription’ (15). But teachers suffer from the lack of emphasis placed on a non-statutory PSHE. Many simply don’t want to teach it (16) and this is unsurprising when support from schools is variable.

Research has found that only 28% of secondary school teachers find it easy to be released for PSHE CPD training and only 21% find it is easy to get funding (17).  Teachers may also feel uncomfortable talking about sensitive and controversial issues without adequate training (18) resulting in topics such as sexuality, mental health and domestic violence being dropped.

Practical, innovative input from schools is vital to improving PSHE provision and evidence points towards an integrated approach (20).  In 2012, the Royal Society for Public Health (RSPH) hosted a workshop with stakeholders across health and education who stressed the need to move away from responding to deficits by combating bullying or teaching sex education and healthy eating as isolated issues. Good practice was seen not just as providing information to pupils but building confidence and resilience, including the ability to take measured risk and make active decisions, both of which are believed to be key determinants of individual health action (21). Schools that perform well put health and development at the heart of their curriculum and ethos (22).

One way to nurture these skills is through a peer-led approach. The Youth Health Champions initiative, piloted by North East Essex Primary Care Trust, trained students as facilitators of health education and to act as signposts for their peers. This has been developed by RSPH into a movement to engage young people in their own health journeys. In schools, Youth Health Champions consult with teachers on content and work with small groups during PSHE sessions with feedback indicating messages are ‘far more relevant and easy to understand when delivered by… their contemporaries’ (23).

Crucially, delivery can be approached by schools in partnership with public health authorities to target specific public health interventions in addition to meeting learning goals. The PSHE Association has, for example, supported Portsmouth City Council’s Health Improvement team to assess local public health priorities and adapt a programme of study to suit their needs – truly using the subject as a bridge between education and public health.

It is now time to strengthen this bridge with statutory underpinning. Caroline Lucas, whose bill to introduce statutory PSHE will be read in parliament for the second time in late February, has said: ‘as long as PSHE remains a non-statutory…subject…there will be virtually no coverage…in teacher training. In school, PSHE teachers are not given the curriculum time or training that they need – statutory status is key.’

We must get serious about empowering children and young people to manage their own health if we are to see changes in worrying health indicators. If we don’t do this in schools, where will we do it?

1) PSHE Association
2)  Cancer Research UK
3) RCN
4) FPH manifesto, ‘Start Well, Live Better’,
5) ‘Key Data on Adolescence for 2013’ published by the Association for Young People with the support of Public Health England
6) Chief Medical Officer’s Report, 2012
7)  RCN
8) RCN
9) Chief Medical Officer’s Report, 2012
10)  PSHE Association
11) Ofsted report on personal, social, health and economic education in English schools in 2012
12) Independent Review of the proposal to make Personal, Social, Health and Economic Education statutory, 2009
13) Ofsted 2012 report
14) Ofsted 2012 report
15) Draft Written Statement: links to a pdf
16) Kath Sanderson, ‘Health education in schools: strengths and weaknesses in relation to long-term behaviour development’, Perspectives in Public Health, DOI: 10.1177/1757913911430915
17) Formby et al, ‘ Personal, Social, Health and Economic (PSHE) Education: A mapping study of the prevalent models of delivery and their effectiveness’, January 2011
18) Ofsted report, 2012
19) Ofsted report, 2012
20) Formby et al, ‘ Personal, Social, Health and Economic (PSHE) Education: A mapping study of the prevalent models of delivery and their effectiveness’, January 2011
21) Kath Sanderson, ‘Health education in schools: strengths and weaknesses in relation to long-term behaviour development’, Perspectives in Public Health, DOI: 10.1177/1757913911430915
22) Lolc Menzies, ‘Charting a Health Literacy Journey – overview and outcomes from a Stakeholder Workshop’, Perspectives in Public Health, DOI: 10.1177/1757913911431041
23) Martin Page, ‘How to avoid ‘dad dancing’: a peer-led approach to the delivery of health education in secondary schools’, Perspectives in Public Health, DOI: 10.1177/1757913911430913

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