Better Health For All

by Martin Dockrell FRSPH  

Director of Research & Policy
ASH

The Health Secretary has opened a consultation  on plain standardised packaging for the tobacco industry, picking up a proposal first mooted by Alan Johnson when he was Labour’s Secretary of State for Health. It is no surprise that the idea receives all party support and strong public support too: the Plain Packs Protect website already has over 40,000 supporters.

A previous consultation received almost 100,000 responses, and 98% of those responding on plain packaging supported the measure. An ASH analysis of the handful of opponents showed many had undisclosed links to the tobacco industry. Nonetheless, the Labour Government felt more evidence was needed to justify action.

Since then the research has piled in. A study ASH published was one among many to show:

• Plain packaging reduces misleading messages to smokers (manufacturers use colours like silver, blue and gold to hint that some brands are less harmful than others, apractice so misleading that labelling brands “light” and “mild” is now illegal)
• Plain packaging gives greater impact to health warnings.
• Most important of all, plain packs are much less attractive to young people.

Plain Packs

As with Labour’s tobacco advertising ban almost a decade ago, adult smokers will not have their choice constrained – any who want to will continue to buy their favourite brand – and as with the advertising ban, we can expect to see a steady reduction in the numbers of young people starting to smoke. The only people who will be constrained will be tobacco manufacturers.

Australia has already passed a similar law and will implement it by the end of the year. Needless to say the tobacco industry fought it tooth and nail. Supposed retailer front groups ran election time TV ads against Australia’s Labour party but it was soon discovered that it was the tobacco manufacturers who were paying the bills.

Industry disinformation failed to convince the Australian electorate and legislators. Big Tobacco lost in parliament and is now trying to use trade agreements to overrule the health policy of a sovereign government. Their favourite ploy is to claim that plain packs will be easier to counterfeit. In fact, existing packs are no obstacle to counterfeiters. The truly effective way of stopping fakes is to have invisible markers on the packs. These already exist and will continue.

It is no surprise that they are fighting so hard. Market failure has made UK tobacco companies among the most profitable in the country. Just two companies hold 84% of the UK market and one of them – Imperial Tobacco – made over £3bn profit on just less than £7bn tobacco revenues. The industry knows that one cigarette is much like another and in blind tests smokers struggle to tell them apart.

That makes packaging key to these huge profits because it allows manufacturers to sell premium brands at close to £8 per pack while using the excess profits to cross-subsidise “value brands”, selling for less than £5.50. That way they reduce the incentive for poorer smokers who want to quit. Companies may blame the Chancellor for the cost of smoking but every time the tax goes up they take a little extra for themselves.

The reason all this matters for the left is that the main function of the tobacco market is to redistribute wealth away from the nation’s poorest families in favour of the City’s most profitable companies. And the poor pay for smoking in more ways than one:  Smoking rates are so much higher among poorer communities that half the difference in life expectancy between richest and poorest is down to smoking alone. But poor smokers can leap the health gap by quitting. After all, the poorest non-smokers have a better life expectancy than the richest smokers and research by Professor Robert West shows poorer smokers are just as likely to want to quit as rich ones. They are just as likely to try to quit too but they are half as likely to quit successfully.

Will health campaigners succeed this time when we failed under Labour? Not only is the evidence out there now, but popular support has grown. Annual polls show that support had been growing gradually since 2008. This year we changed the question, showing people what a “plain pack” might look like and support leapt up to 62% while opposition melted away to 11%. Even among smokers, for every five who thought it was a bad idea we found six who supported it.

The Food Growing in Schools report highlights compelling evidence that proves food growing in schools helps support children achieve, builds life and employability skills, and improves their health and well-being. The report was published in March 2012 by a Taskforce led by the charity Garden Organic alongside 25 members, including Morrisons Supermarket, Forestry Commission and the Royal Horticultural Society. It is supported by FPH.

Having proven the benefits of food growing, the Taskforce is now urging for providers, society and business to come together to ensure that in future every child is involved in food growing as part of their school experience. Children across 80% – or 26,000 – of England’s schools are now involved in some level of school food growing, thanks to school initiatives including the Big Lottery funded Food for Life Partnership and charitable programmes like the RHS Campaign for school gardening.

The Taskforce looked at evidence from all of these schemes and more, alongside academic research including an independent report from National Foundation for Educational Research (NFER), which surveyed 1302 schools and undertook a systematic literature review, contributing weighty evidence confirming that school food growing activity:

• Encourages and facilitates learning – particularly in science

• Builds skills, including life, enterprise and employment related skills

• Improves awareness and understanding of the natural environment

• Promotes health and well being in relation to diet and nutrition

• Supports school improvement and development

• Strengthens communities and interaction.

Improves achievement

A stand out finding of the report was the benefit school food growing activity had on academic achievement. Schools cited supporting the outdoor curriculum (68%), supporting the science curriculum (57%) and supporting the food technology curriculum (39%) as motivations for growing food in their school. Further evidence showed enhanced scientific understanding, numeracy, literacy, and language skills.

Builds life and employability skills

Aside from the emphasis on improving learning, the Taskforce found that the activity of growing food in schools also supported the acquisition of life skills, including financial literacy and enterprise skills. Interestingly communication and employment skills were also enhanced. It also found signs of improved motivation and behaviour, for example arriving early to school and leaving later, increased attendance and completion of homework and less disruptive classroom behaviour.

Improves health and wellbeing

One of the report’s key findings is the evidence that proves school food growing promotes good health through improved diet and nutrition and better well-being through improved self-esteem and self confidence. 73% of schools cited teaching children about nutrition as a motivation for food growing, 68% for giving them skills for a healthy adult life and 33% for encouraging exercise. Evidence showed improved understanding of food and nutrition, increased willingness to try fruit and vegetables and increased consumption of fruit and vegetables, and school meals where food grown in school is incorporated into school catering were also increased.

Vishnee Sauntoo
No Smoking Day Campaign Marketing Manager

Wednesday 14 March is the 29th annual No Smoking Day and is one the biggest public health awareness campaigns of its kind.

Each year, up to one million smokers make a quit attempt on No Smoking Day. Not only is the campaign one of the most cost-effective smoking cessation campaigns (Kotzet al. Tobacco Control 2010) costing less than £100 per quality life year saved – it is one of the highlights of the public health calendar, with true partnership-working in the local community.  Stop smoking services, local authorities, nurses, pharmacies, GP practices, opticians, schools, occupational health professionals and many others get involved in creating fun, inspiring events to encourage smokers to quit on the day.

Smoking rates have gone down from 40% in 1984 to 20% in 2010 but there are still 9.5 million smokers in the UK.  So it is up to all of us in the public health arena to ask ‘do you smoke?’ because we know that two-thirds of smokers want to quit but find it really difficult.  The job of public health professionals is to raise awareness and signpost effective methods of quitting and what better way than to remind the public of No Smoking Day.

Whether you work in environmental health, trading standards, the NHS, schools, colleges or a workplace, you will face a smoking issue at some point in your career.  So leap on board with this year’s theme Take the Leap and inspire hundreds of thousands to quit on Wednesday.

So far, we’ve been spreading the word using 3D street art and encouraging MPs to support their constituents to quit.  We will also be driving lots of local media coverage with events in local areas and putting out a story about the rise of shisha (waterpipe smoking) bars in the UK.

If you want to support smokers to quit, encourage them to contact their local NHS stop smoking service, join our facebook page, Twitter page or visit our dedicated smoking cessation website WeQuit.

Above all, don’t forget to ask ‘do you smoke?’ because you never know they might reply ‘yes but I really want to quit’.

by Corinne Camilleri-Ferrante
Consultant in Public Health Medicine

The recently published Design of the NHS Commissioning Board (CB)  “presents recommendations for the organisational design of the NHS CB”. This was followed by the Commissioning Intelligence Report, which contained the Commissioning Intelligence Model. The juxtaposition of these two documents highlights the lack of joined up thinking about NHS commissioning and, the involvement of Public Health (PH) in commissioning NHS services.

The Design paper lays out the constituent functions of the NHS CB. It explains that there will be corporate teams and that the approximately 3,500 strong workforce will be committed to matrix working. What it most spectacularly does not talk about is public health involvement. There are medical, nursing and operations directorates but none have identified PH posts within them.

The Commissioning Intelligence Model has been written largely to inform the intelligence needs of CCGs for commissioning. This report makes many valuable points about the need for timely, accurate data to enhance patient care and commissioning. When I got to the Commissioning Intelligence Model, the full impact of what I was reading struck home.  It could be a diagrammatic representation of the Health Services Public Health parts of the FPH curriculum. This is what every PH consultant is trained to do, and what health services PH specialists have spent years perfecting, studying and improving.  The Commissioning Intelligence Report says that discussions with PH in LA will be necessary. This totally misses the point.

There are two fatal flaws in the reasoning behind these documents.

1.    CCGs will need this commissioning intelligence, but it is a fundamental part of the commissioning process, not a bolt-on extra.. This has to be embedded in the commissioning process, so that the conversion of data into useable information for clinicians and others involved in commissioning is seamless. This will not happen if it is seen as something separate from the main commissioning focus. Health services PH professionals need to be embedded with CCGs, not sitting in LAs offering ‘advice’.
2.    If this is necessary for CCG commissioning, then surely it must also be necessary for the NHS CB. Yet nothing in that document mentions it. Why this resistance to PH at the level of the NHS CB? How will the NHS CB ensure it has commissioning intelligence if it has not got the expertise within it? To say that Public Health England will offer such advice as is necessary is, again, to miss the point of the reality of every day working, taking hearts and minds with you in managing difficult decisions.

Commissioning intelligence is going to be vital if the challenges facing the NHS are to be met. Commissioners have to be properly trained in all aspects of population health. The NHS already has a fully trained cadre of professionals ready to undertake the work. Some of us have been doing it for years. Importantly, we are the only group who can guarantee that we have maintained our skills and who can bring together all the skills demonstrated in the model.
If the jobs are not guaranteed by Faculty standards, where are the safeguards for the future when the current crop of PH professionals retires?

by Dr  John Middleton and Dr Corinne Camilleri-Ferrante
(writing here in a personal capacity)

Since before Christmas, women have been concerned by the revelations about faulty implants used in breast surgery. There has been much debate about whether or not these should be removed and, if so, who should foot the bill. The expert committee convened under Sir Bruce Keogh, Medical Director of the NHS, reported Friday 6th January. However, many Faculty members fear the issue is just one small example of what might happen on a larger scale if the changes to the health service now  going through Parliament proceed without proper risk assessment/ challenge.

The revelations of multiple failures, of manufacture, regulation, and responsibility, should make Peers consider the facts very carefully. The government proposes a vast increase in private provision of health care just as we are told that existing private providers are unable to supply adequate records of what they have been doing and are charging women for information on what happened to them.

There is complete confusion about who is responsible for putting things right, except that we know it is not the manufacturer, which has ceased trading. Private companies are citing ‘commercial confidentiality’ as a reason for not producing data. Yet, Peers are now being asked to endorse a Bill that may increase the risk of such events occurring without being able to see the government’s risk register.

The Bill will lead to further fragmentation of data collection, as the Faculty has said, and contains no clear failure regime for private providers. This will be even worse than the failed data collection which meant that the Independent Sector Treatment Centres established by the last government were unable to provide data to assess whether they were providing value for money, or even complying with the terms of their contracts.

This has just been one example of the failure of private provision with a  requirement for the NHS to pick up the pieces, as local authority care has had to step in with the Southern Cross disaster. Such examples show how services  provided by the taxpayer are then required to divert their resources from other pressing needs. And there is little come back for the private citizen, the patient, caught in the middle of this failure.

There is also an additional cause for concern. The Secretary of State for Health was interviewed about the breast implant issue on Radio 4’s Today programme Wednesday 4th January.  Under current legislation and under a clause that has stood since the beginning of the health service, the Secretary of State has a duty to secure, and to provide comprehensive health care for all.

In the new Bill, this Duty to Provide will be removed. The Secretary of State will be able to disclaim responsibility and say that it is the responsibility of each Clinical Commissioning Group that authorized their use. The Secretary of State has been  reduced to exhorting  private providers to fulfill their moral duties but has no  authority to  make them.  If the Health Bill becomes law, who will then be interviewed on the Today programme, stand up and be counted and admit, ‘the buck stops here?’

‘Medical’ and ‘public’ health

By Sir Richard Thompson, President of the Royal College of Physicians

Prevention is better than cure. It is a cliché, but it is true. There are opportunities within public health policy to address the rising demand on the NHS and other public services. It is obvious to me that the future viability of the NHS depends on a coordinated approach to public health, nationally and locally.

Secondary care specialists and public health doctors are crucial, providing specialist knowledge and expertise on clinical issues and the health of the population.

Giving local authorities greater public health responsibility does give us an opportunity to tackle the broader social determinants of health, such as housing and air quality. However, there is a risk that there will be a dislocation of ‘medical’ and ‘public’ health.

To avoid this, we need to take an integrated approach. I believe public health specialists should also sit on the board of all Clinical Commissioning Groups (CCGs) and the NHS Commissioning Board. Reciprocally, hospital doctors should be represented on Health and Wellbeing Boards, which will be based in local authorities. This will help to develop and strengthen their links with the NHS.

I have been calling for the statutory registration of public health professionals. This will help to ensure that directors of public health, and public health staff that support them, have the skills and experience needed for this expert and specialised job. I would encourage the government to give the Health Professions Council the role of regulating public health professionals.

I am extremely sceptical about the Responsibility Deal’s ability to resolve major public health issues, such as obesity and alcohol. The RCP, along with five other health organisations, declined an invitation to sign up to the alcohol responsibility deal because of serious reservations about the proposed alcohol pledges.

There is an inherent conflict of interest when industry drives public health policy, and in particular the alcohol deal only set out a number of aspirational, unenforceable and weak pledges. The ‘carrot’ approach of voluntary agreements with industry is unfortunately not enough to prompt healthy behaviours; it needs to be complemented by the ‘stick’ approach of legislative solutions where necessary.

Recently, the Health Select Committee voiced concerns about the independence of Public Health England (PHE) and I must say that I echo its unease. PHE must be authoritative, independent and able to hold the government to account. To do this, PHE must be visibly and operationally independent of Ministers. Locally, directors of public health must have sufficient influence, and therefore should be appointed to chief officer level within local authorities. They should have the authority to determine the best way of distributing the local authority public health budget.

There are opportunities within public health policy to address the rising demand on the NHS and other public services; they must not be missed. The government must use all available levers to improve and protect the health of the population, otherwise the NHS will be swamped.

Download the RCP’s public health submission to the NHS Future Forum.