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  • By Deborah Arnott
  • Chief Executive
  • Action on Smoking and Health (ASH)

In the UK, smoking kills around 100,000 people a year (1). To replace those who quit or die, the tobacco industry has to continually recruit new smokers. As most people start smoking before they’re 18 it is children and young people who the industry must recruit (2). Advertising and marketing has been shown to increase the appeal of cigarettes to children and tobacco manufacturers design their packs to be glitzy and glamorous with often novel designs resembling such things as perfume packaging.

This is a tactic that works: around 207,000 young people start smoking annually in the UK (3) and exposure to tobacco marketing has been shown to increase this risk (4). Children from the most deprived backgrounds, where smoking prevalence is highest, are most likely to be exposed to tobacco packaging (5). Of those who become lifetime smokers, 1 in 2 of will die of a smoking-related disease (6).

Standardised packaging is the best way to protect children from the lure of sophisticated tobacco industry marketing and the FPH’s new manifesto for public health in the next parliament rightly identifies standardised packaging as vital in giving children the best possible chance of achieving a healthy future (7). However, to maximise the public health gains possible from standardised packaging we need to act now to make sure legislation is voted on by this Parliament.

As part of The Children and Families Act, which became law in February 2014, MPs voted in favour of powers enabling the Government to introduce regulations requiring standardised packaging for tobacco products (8). Since then, the Government has published and consulted on draft regulations. To bring the legislation into effect, these regulations need to be put before Parliament for a further vote. The revised Tobacco Products Directive from the European Parliament, which contains a series of measures intended to deter young smokers including larger health warnings, will be implemented in the UK by May 2016 (9). Because measures have a cumulative effect, implementing standardised packaging at the same time will maximise the public health gain; for this to happen Parliament must be given the chance to vote on the regulations to introduce standardised packaging before the next General Election.

The tobacco industry is running a well-resourced and highly misleading campaign against the introduction of standardised packaging in the UK, but the evidence base for the measure’s effectiveness is now well-established. In April this year, Sir Cyril Chantler’s government-commissioned independent and comprehensive review of evidence reported that there is a strong public health case for the policy, concluding that “the body of evidence shows that standardised packaging… is very likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking and thus have a positive impact on public health” (10).

Moreover, despite claims from the tobacco industry that standardised packs will lead to an increase in tobacco smuggling, the proposed packs would contain the same security markings as existing packs and would be no easier to counterfeit. Sir Cyril Chantler stated in his review that he was “not convinced by the tobacco industry’s argument that standardised packaging would increase the illicit market, especially in counterfeit cigarettes” (10).

An industry-commissioned report using sales data from Australia to claim that there has been an increase in tobacco sales since the introduction of standardised packaging has been widely dismissed. Although the industry reported a small (0.28%) increase in sales year on year, they did not report the increase in the Australian population between 2012 and 2013. Adjusted for population, tobacco sales per person have in fact fallen (11).

Tobacco industry efforts have also failed to dent the popularity of standardised packaging, which currently has strong support from the public, politicians across the political spectrum and the public health community (12). A YouGov poll in March 2014 found that overall 64% of adults in Great Britain support or strongly support plain standardised packaging with only 11% opposed to the measure (13) and when Parliament voted to give the Government the power to introduce standard packs through regulations, 453 MPs voted in favour and just 24 against.

Evidence from Australia, the first country to introduce standardised packaging in December 2012, has been encouraging. Soon after standardised packs began to appear in shops, smokers reported that they found cigarettes in these packs less appealing or satisfying (14). Research has also shown that smokers consuming cigarettes from standard packs were 81% more likely to have thought about quitting at least once a day during the previous week and to rate quitting as a higher priority than smokers using branded packs (14).

Every day since the publication of Sir Cyril Chantler’s review in Spring 2014 hundreds of children have started smoking and the public health community has a responsibility to ensure this number stops growing. You can help make the case for standardised packaging by writing to your MP and urging them to encourage the Government to bring regulations to Parliament as soon as possible.

References and notes
(1) ASH Fact Sheet, Smoking Statistics: Illness and death, 2014
(2) Office for National Statistics. General Lifestyle Survey Overview: A report on the 2011 General Lifestyle Survey. 2013.
(3) ASH Fact Sheet, Young People and Smoking, 2014
(4) The packaging of tobacco products. March 2012. The Centre for Tobacco Control Research. Core funded by Cancer Research UK.
(5) Marmot, M. et al. (2010) Fair Society, Healthy Lives: Strategic review of health inequalities in England post-2010 Marmot review secretariat, London
(6) Doll, R. et al. (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004; 328: 1519
(7) Faculty of Public Health, (2014) Start Well, Live Better – a manifesto
(8) Children and Families Act 2014
(9) Tobacco Products Directive 2014
(10) Standardised packaging of tobacco. Report of the independent review undertaken by Sir Cyril Chantler. Kings College London, April 2014
(11) Is smoking increasing in Australia? The Guardian, June 2014
(12) The Smokefree Action Coalition an alliance of over 250 health organisations including medical royal colleges, the BMA, the Trading Standards Institute, the Chartered Institute of Environmental Health, the Faculty of Public Health, the Association of Directors of Public Health and ASH, all support the introduction of standard packs.
(13) The poll total sample size was 12,269 adults. Fieldwork was undertaken by YouGov between 5th and 14th March 2014. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+). Respondents were shown what a standard pack could look like, including larger health warnings as in Australia.
(14) Wakefield M et al (2013); Introduction effects of the Australia plain packaging policy on adult smokers: a cross-sectional study; BMJ Open 2013

Originally posted on CyclingWorks:

fph-logoThe Faculty of Public Health is the standard-setting body for specialists in public health in the United Kingdom. It is a joint faculty of the three Royal Colleges of Physicians in the UK, and is the home of 3,000 professionals working in public health. For more than 40 years they have been at the forefront of the transformation of the public health profession.

The Faculty sent this letter to TfL outlining the strong public health benefits of the scheme and urging its adoption. The letter points out TfL’s commitments under the Transport Action Plan from February of this year to increase active travel and make streets safe and inviting for all users.

We welcome Transport for London’s proposals for the creation of East-West and North-South cycle superhighways.

The National Institute for Health and Care Excellence (NICE) recommends the facilitation of active travel through improvements to infrastructure. The creation of cycle superhighways incorporates…

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  • by Madeleine Harris Smith
  • Policy & Advocacy Manager
  • Alcohol Health Alliance

Every single hour a person in the UK is killed by alcohol (1). Every single month, 75,000 violent incidents take place where the victim believes the offender to be under the influence of alcohol (2). Every single year, 1.2 million people are admitted to hospital due to alcohol-related causes (3).

Behind every single one of those statistics is a loved one – a friend, a parent, a sibling, a child.

And alcohol does not just harm the individual drinker; it all too often affects innocent bystanders, through its role in child abuse and neglect, domestic violence, family breakdown and crime and disorder. And as well as the human toll, alcohol costs our country £21 billion every year (4).

The availability of alcohol has increased far beyond the local pub, and is now 61% more affordable than it was in 1980 (5). The majority of alcohol is now sold in supermarkets and off licenses, where it is routinely offered at less than cost price to entice people into stores (6) – a can of super strength white cider, such as Frosty Jack’s, can currently be sold for about 16p. Of all alcohol sold, very cheap products play the biggest part in driving alcohol-related harm (7).

Due to existing health inequalities the cruellest effects of alcohol are felt most by those who can least afford it, due to existing health inequalities. Even though as a group they don’t consume as much alcohol as more affluent groups, people in the most deprived areas of the country are disproportionately more likely to experience the impacts of alcohol-related crime, are more likely to suffer the impacts of alcohol-related health conditions and are more likely to die from an alcohol-caused condition (8).

There isn’t one ‘silver bullet’ to fix this epidemic, but in terms of building an effective alcohol strategy for the UK, implementing a minimum unit price must be the foundation stone. A minimum unit price would allow all alcoholic beverages to be priced based on their strength, with stronger drinks, such as high-strength white cider and spirits priced higher than their lower-strength alternatives. This precisely targets the products that are consumed by young drinkers and people drinking harmful quantities, without penalising moderate drinkers, including those on lower incomes.

Research commissioned by the Government as part of its consultation on the Alcohol Strategy confirms that minimum unit pricing is far more effective at tackling alcohol-related harm than the Government’s current ban on the ‘below cost sales’ of alcohol. A 50p minimum unit price would result in a reduction of 50,700 less alcohol related crimes and a reduction of 35,100 hospital admissions by year ten, alongside an overall reduction in alcohol consumption of 2.5%.

Minimum unit pricing would not adversely impact moderate drinkers, with the price of the majority of alcohol on our shelves and in our pubs remaining unaffected. In fact, moderate drinkers across all income groups would spend just 78p more on alcoholic drinks per year (9).

Minimum unit pricing would play a pivotal role in tackling health inequalities without penalising moderate drinkers on low incomes. As lower income households disproportionately suffer the harms of alcohol, they would see the greatest benefits from minimum unit pricing.

Data from the University of Sheffield suggests that routine and manual worker households would account for over 80% of the reduction in deaths and hospital admissions brought about by a minimum unit price and yet the consumption of moderate drinkers in low income groups would only drop by the equivalent of two pints of beer a year (10).

Minimum unit pricing would also reduce drinking among children and young people, as they are particularly sensitive to price changes, as research into tobacco pricing has demonstrated (11). The affordability of alcohol, and particularly the attractive price promotions in off licenses, supermarkets and other shops, means that it is often cheaper for our children and young adults to drink than to participate in other social activities such as going to the cinema or bowling (12).

We experienced a devastating setback for public health when the Government ‘U-turned’ on implementing a minimum unit price last year, citing a lack of evidence that the level of problem drinking would be reduced without ‘penalising those who drink responsibly’. This is indicative of the misinformation that surrounds the policy and that it is our job, as public health campaigners, to try and dispel.

Alcohol tears apart families and damages entire communities – its impact is felt across the board and there is not a neighbourhood in the UK that remains untouched. We are experiencing nothing short of a national crisis because of alcohol – we must act now to stop this.

1)  ONS, Alcohol-related deaths in the United Kingdom, registered in 2012 – ONS. 2014. Accessed June 19, 2014.
2)  ONS, Focus on: Violent Crime and Sexual Offences, 2011/12. 2014. Accessed June 19, 2014.
3)  Gov.uk. Reducing harmful drinking – Policy – GOV.UK. 2013. Accessed June 19, 2014.
4) HM Government, March 2012 ‘The Government’s Alcohol Strategy’ Cm 8336 201, para 1.3
5) Health and Social Care Information Centre. Statistics on Alcohol: England, 2013. 2014. Accessed June 19, 2014.
6) Bennetts R. IAS Briefing Paper: Use of Alcohol As A Loss-Leader. Institute of Alcohol Studies; 2014.
7) Bennetts R. 2014, Ibid
8) North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University. New Local Alcohol Profiles for England reveal the poorest suffer the greatest health harms from booze culture.; 2012.
9) Holmes, J. et al, Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study’ The Lancet, Published online February 10, 2014  Last accessed 30 May 2014
10)  Holmes, J. et al, (2014) Op Cit.
11)  Zhang, B., Cohen, J., Ferrence, R., and Rehm, J. The Impact of Tobacco Tax Cuts on Smoking Initiation Among Canadian Young Adult. American Journal of Preventive Medicine, 006;30(6):474–479; Rice, N. et al. A systematic review of the effects of price on the smoking behaviour of young people. (London: LSHTM, 2009).
12) The Cinema Exhibitors Association Limited. UK cinema – average ticket prices 2000-2013, Last accessed 18 June 2014; YouGov. Cinema cost concerns mount. Last accessed 18 June 2014

This blog is the first in a series that looks at the story behind each of the 12 priorities in Start Well, Live Better, FPH’s Manifesto for the 2015 General Election. The Transatlantic Trade and Investment Partnership (TTIP) could impact on one of the 12 priorities: the ability of a UK government to provide a universal healthcare system, free at the the point of delivery.

 

  • John Middleton
  • Vice President for Policy,
  • United Kingdom Faculty of Public Health

The Faculty of Public Health is concerned about the damaging potential of the Transatlantic Trade and Investment Partnership (TTIP) for public health, environmental protection and sustainability.

TTIP is being touted as a major benefit for trade between the European Union and America.  But the means by which greater trade is to be gained is through deregulation of standards of health and safety, standards in consumer safety, environmental, and public protection.

The deal is also likely to further add to global warming and climate change.  Alongside the TTIP is a secretive and disturbing quasi-legal instrument known as the Investor State Dispute Resolution scheme (ISDS). This process enables investors to sue governments if they believe their right to profits are being damaged by national policies which may be promoting health, or protecting workers or environments.  The proceedings of ISDS are already evident around the world and should be a concern to all those working for better public health and the environment.

A lot has been written about the TTIP and its implications for the NHS.  Trade unions, politicians, the Royal Colleges and the Lancet have voiced concerns and called for NHS services to be exempted from the trade agreement.  UK government ministers have not shown any inclination to ask for the NHS to be exempted from the agreement, which would be in their powers to ask for.  Why would they? When the stated objectives of the Health and Social Care Act 2012 were to open up competition in the health service? Bizarrely, they have also implied that TTIP will offer a competitive edge for the NHS – a great service that should somehow play on the world stage, subsidised by the taxpayer. We are short of midwives in the UK so how we would sell such services to the US or Europe is a mystery.

European commissioners have issued reassuring statements that the NHS will be exempt. But EC commissioners cannot give such assurances. Once the TTIP is signed and provisions for the Investor State Dispute Resolution (ISDS) are in place these are legal agreements for which grievances and claims for compensation can be pursued in a quasi-court.

Any company with a stake in the NHS now could easily cry foul, take recourse to the dispute scheme and claim compensation if their NHS pickings are not to be protected indefinitely.

TTIP and the ISDS are secretive, policed by a few international lawyers, in a self-serving arrangement, using their knowledge and expertise as the arbitrators, or the advocates. The process, rides rough shod over national law, undermining the entitlement of states to legislate for the improved public health and protection of their citizens.

TTIP presents a much bigger threat to the public’s health, much bigger even than the potentially devastating impact on the NHS, TTIP threatens health and safety conditions, hard-earned workers rights, terms and conditions and protection in employment and threatens local and global environmental safety and controls, carbon emissions and global warming.  It also threatens to dumb-down consumer safety standards – for example through raising permitted levels of antibiotics in foods.

FPH’s manifesto for all the political parties in the next election includes major recommendations for laws designed to protect and improve the public’s health. A sugar tax, minimum unit pricing of alcohol, a living wage, and reducing carbon emissions  – all of these proposals could fall foul of TTIP and its ISDS. If a future government chose say, to accept the overwhelming international and national evidence and implement a minimum unit pricing of alcohol, The Big Alcohol companies could well demand compensation for lost profits, likewise Big Food, on a sugar tax.

It’s easy also to see the ‘chillers effect’ making governments think twice even about implementing such legislation. Multinational companies demand complete freedom to sell their goods whatever the consequences to society. In the case of alcohol, governments pick up the cost of policing violence, and treating disease; other private and public employers pay the costs of alcohol in workplace inefficiency and absenteeism. Big Alcohol pockets the profit.

Strong intellectual property protections afforded under TTIP to pharmaceutical companies may dangerously increase the sphere of influence of big pharma over national regulatory standards. The sovereign power to promote access to medicines and EU transparency requirements over clinical data is at risk.

Supporters of the TTIP quote Obama’s promise of an average $680 per household benefit from the trade agreement. Even if this figure is correct and we take it at face value, would it be a gain worth having? $13 a week gained per household set against potential losses of salary, jobs and working conditions, and the environmental damage of extra consumption for our children to cope with?

And of course, past evidence of major economic change suggests benefits are not delivered equally. There will be big winners and therefore big losers. The narrow margin of benefit is such that gains for bankers, investors, and industrialists will mean loss of money and jobs for many, and destitution heaped on the poor.

Trends towards widening inequalities in income over 40 years in the UK and other parts of the world have been accompanied by widening gaps in the ill health and life expectancy between rich and poor. In 35 years since the Black report, Whitehead, Acheson, Wilkinson and Marmot have all expanded this overwhelming body of knowledge.

Economic inequality causes health inequalities; poverty kills. We can expect widening inequality in health if this trade agreement is signed.

Supporters of the agreement also suggest fears of over use of the ISDS are also unfounded. However, there are recent examples of investor-state disputes which threaten health and the environment which suggest that recourse to these processes is likely to become more common and more damaging to sovereign government’s attempts to legislate for health and the environment.  These were illustrated in the  New Scientist

The most visible at present is the Phillip Morris Uruguay case where the Marlboro man is asking for compensation for lost earnings as Uruguay prepares the most severe health warnings on packs in the world. Surprising perhaps that a tobacco company now says this public health measure will work and will hit them in the pocket when they have denied such measures will be effective throughout the history of tobacco control. Swedish energy giant Vattenfall is taking Germany to the arbitration tribunal for its decision to move away from nuclear power following the Fukushima disaster.

Lone Pine, the multinational oil and mining company, is suing the Quebec government for  $250m over their decision to place a moratorium on fracking.  Occidental was recently awarded over $1.7 billion compensation following their eviction from Ecuador, despite having broken Ecuadorian laws. Achmea, the Dutch health insurance company sued Slovakia for the change of health service policy, which required health insurers to operate on a non-profit basis. Veolia is suing the Egyptian government for raising the minimum wage of water treatment workers.

The potential benefits of TTIP for the UK are projected to be in pharmaceuticals, the motor industry and chemicals- in any objective sense, in the context of global warming, these are all industries we need less of – to protect our environment, to stop poisoning people and, increasingly in the era of big pharmacy, to stop damaging our health.

None of these industries are now major job creators per given investment and could only increase at the margins. None of these have any credibility in terms of social and corporate responsibility.  The whole idea that economic growth for its own sake is a good thing now needs to be seriously challenged.  GDP does not buy us happiness. We need a more sustainable people-centred economy, which supports localism. The very businesses to be sacrificed in this deal are the so-called American  ‘mom and pop’ businesses; the main proponents of this deal are the multinationals. Living within our means in order to protect our children’s future is the new imperative.

For all these reasons, it is right that there is a growing disquiet about this sinister and clandestine negotiation. FPH believes it will damage health, create poverty and damage the environment now and in the future. It will make prospects for laws to protect and promote the public’s health far less likely to happen in the future.

If you are not an advocate for this agreement, it is unlikely the benefits will be coming your way.  It is likely to benefit only a very small proportion of people in the upper echelons of societies on either side of the Atlantic, or in far off tax havens. If you are not for it, you should be against it.  Anybody who is not heading a big multinational company should reject it and campaign vigorously to ensure it never becomes a reality.

This blog is reproduced by kind  permission of  New Scientist,  which published a shorter version  of it on November 1st  2014. This was part of a larger opinion feature about TTIP.

  • by Maya Twardzicki – Public Health Lead Surrey County Council, and
  • John Ryan, comedian, Lift the Lid Productions

There is “growing international acceptance of the notion that participation in the creative arts can be beneficial for wellbeing and health” (1) (2).  Although little of this research has focused on comedy as a creative art form, a review of effective health education approaches with young men showed humour is effective when communicating about sensitive topics such as mental health. (3)

Findings from a recent randomised control study suggest that mental health comedy might generally reduce stigma in people who use affiliative style humour (4). In a series of innovative public health projects in Surrey, post-show evaluation also showed comedy to be an effective way to raise awareness, get people talking and generate more positive attitudes about mental health in both the general and prison populations. (5)

Much stigma still surrounds mental health: 87% of service users reported its negative impact on their lives. (6) Stigma in the military population is also common, (7) more so among those with a mental disorder. It is an important contributing factor to the challenge of engaging military personnel with psychological support (8)   as it is known to be a barrier to seeking help. (9)

The challenge in reducing stigma in both public and military populations, is to achieve lasting attitude change. Although evaluation of the Time to Change public campaign indicates longer term attitude change, several anti-stigma interventions implemented in the UK armed forces have failed to modify stigmatising beliefs at longer follow up.

So together with the Academic Department of Military Mental Health at Kings College London, we tapped into the strong role of humour in military culture to evaluate the short and longer term impact of stand up comedy as a novel stigma-reduction in a sample of Army service personnel.

Focus groups were run with Army service personnel to help inform the mental health comedy show script and explored their experiences of mental health, related attitudes and barriers to help seeking.

“We asked the men how they exercise their most important organ, they were surprised to realise it was their brain and how it benefits from wellbeing.” John Ryan, Comedian.

Personnel viewed a regular comedy show, which acted as a control, or a show containing mental health information and an additional comedian with experience in the military and of mental health problems. `Social contact` between those with and without mental health problems is an effective way to encourage more positive attitudes. (10)

John Ryan: “I said a good way to take control of your anxieties is to always finish what you start.  A lad replied ‘I finished my pint and watched the rest of the football match but didn’t feel any better’ “.

Before the show, immediately after and three months later, measures were taken (using recognised instruments/scales) of: military-based stigmatisation, potential discrimination, mental health related knowledge, self reported help-seeking and coping behaviour, talking about mental health, current mental health and alcohol use. Response rates were high pre and post show, but unfortunately very low at three month follow up due to many of the sample preparing to be or being deployed.

  • Satisfaction with the comedy show format was very high showing that it was an acceptable way to present mental health related messages.
  • Post-show, intervention group participants reported significantly less stigmatisation and were significantly more likely to answer mental health-related questions correctly
  • In the small sample at follow up, neither difference was maintained. However, there was a borderline significant reduction in potential discrimination; and intervention group personnel were statistically significantly more likely to discuss mental health and advise others about mental health. Adjusted analyses suggested that this may have been related to factors other than the show (e.g. greater opportunity to do so as the intervention group had higher levels of common mental health problems)
  • Knowledge of effective coping strategies rose in both intervention and control groups post show, and was significantly higher in the control group at follow up. Although this was encouraging as the project did aim to increase personnel knowledge about help seeking, as this effect was seen in both groups, it may have resulted from both unintentional confounding  (project staff who viewed both shows reported that there was some unplanned overlap in the content of the control and intervention shows), and from low follow up numbers.

In conclusion, embedding mental health awareness within a comedy show format had a short-term positive effect upon military mental health stigmatisation in a sample population of UK Armed Forces personnel and was a well accepted/popular format. The reduction in stigma was not sustained at the longer three-month follow up (a finding reflected in other anti-stigma interventions in military populations using mental health awareness or psycho education). (11)

However, the low rate of follow-up limited our ability to assess whether this effect was lasting. It may also be that the intervention has maximum immediate impact and if the Armed Forces finds a way to reinforce the key messages over time, the positive post show changes may prove more durable. If the longevity of change can be adequately assessed and demonstrated in further research, comedy could potentially form a component of a comprehensive stigma-reduction strategy. (12)

1)  Clift S (2012)  Creative arts as a public health resource: moving from practice-based research to evidence-based practice.  Perspect Public Health 2012 May, 132(3):120-7
2)  Stuckey H L, and Nobel J  The Connection Between Art, Healing and Public Health: A Review of Current Literature.  Am J Public Health. 2010 February, 100(2); 254-263
3)  Lloyd T (2002)  Boys and young men’s health: what works.  Health Development Agency. London
Corrigan P W, Powell K J, Fokuo J K, Dosvluk K A (2014)
4) Does humor influence the stigma of mental illnesses?  J Nerv Ment Dis 2014 May 202(5):397-401
5)  Evaluation reports: Dr Claire Henderson and Steve Wright from the Institute of Psychiatry, Kings College London (2010)  and  from Nottingham University Self Harm Research Group (2009)
6)  Stigma Shout Survey: Time to Change
7) Osorio C, Jones N, Fertout M, Greenberg N (2013)   Changes in stigma and barriers to care over time in UK Forces deployed to Afghanistan between 2008 and 2011. Mil Med (in press)
8)  Kim P, Thomas J, Wilk J, Castro C, Hoge C (2010)  Stigma, barriers to care and the use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Sev 61(6):582-588
9)  Capeda-Benito A, Short P (1998)  Self-concealment, avoidance of psychological services and perceived likelihood of seeking professional help. J Couns Psychol 45:1-7
10)  Pinfold V, Huxley P, Thornicroft G et al (2003) Reducing psychiatric stigma and discrimination: Evaluating an educational intervention with the police force in England.  Social Psychiatry and Psychiatric Epidemiology, 38: 337-344.
11)  Mulligan k, Fear NT, Jones N, Wessely S, Greenberg N (2010) Psycho-educational interventions designed to prevent deployment-related psychological ill-health in armed forces personnel: a review. Psychol Med 41:673-678
12) Jones N, Twardzicki M, Ryan J, Jackson T, Fertout M, Henderson C, Greenberg N (2014)  Modifying attitudes to mental health using comedy as a delivery medium. Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0868-2 Published online 09 April 2014

  • By Dr John Middleton
  • Acting President, Faculty of Public Health

The public health settlement announced last week signifies a real-terms decrease in allocations for public health in England.

Local authority officers may have got used to the year-on-year austerity meted out by central government. It has taken out over £10bn since 2011. But the public health community will not be happy to be drawn into the race to the bottom.

The sector’s move from the health service to local authorities was intended to protect public health from decades of stifling under the juggernaut of acute care; to put public health where it belonged and to protect and grow it.

The sum of £2.79bn for 2015-16 is the same amount as last year’s public health ringfence. It is particularly galling at a time when clinical commissioning groups in the health service have had funding increases.

It does not enhance this government’s reputation, nor does it aim to prevent more illness and disability. And it does not suggest central government is any closer to thinking and acting in an integrated way on improving health and independence, and reducing disability and disease.

Figures from Local Authority Revenue Expenditure and Financing: 2014-15 Budget, England show public health budgeted expenditure is £2.84bn, so it would appear that councils are planning to fund the £54m balance from other sources.

The scope for local authorities to apply their funds in a discretionary fashion towards major public health issues is limited – £2.18bn goes on prescribed functions and major commissions in sexual health, drugs and school nursing. In all the other budget areas the amounts committed are puny given the scale of the problems.

There are about 30 director of public health vacancies nationwide and this vacuum enables councils to use public health funds to prop up budgets elsewhere.

We are a huge distance away from ‘industrial scale’ services to prevent smoking, alcohol, dietary and inactivity related ill health.

There is not so much a risk as a certainty that public health money will be diverted to other spending areas. There are about 30 director of public health vacancies nationwide and the senior management vacuum enables councils to use public health funds to prop up budgets elsewhere.

The faculty’s local advisory committees tell us this is happening around the country. Some councils do so for survival; others use finesse to move it to “public health wider determinants budgets” or use funds to reshape existing council services towards more defined health outcomes.

Some directors of public health, striving to be corporate players, are concerned with the reality of protecting services that we have championed as public health services – early years, young people’s job opportunities and welfare rights.

The UK Faculty of Public Health believes the funding allocation for public health is far too small. The amount transferred from the NHS for all public health services was only £4bn although I made the case for another billion to be moved across. Then health secretary Andrew Lansley professed his commitment to protecting and growing public health and getting the nation healthy.

However, it is clear that aspiration remains empty political rhetoric. It is disingenuous of the government to talk in terms of two-year allocations and to answer every challenge from fat and fitness to food poverty and accident prevention by saying “£5bn is available” to tackle them.

Public health services represent less than 3% of local government funding. The overall cut in public services should be the major public health concern. Local government budgets have been hammered relentlessly over recent years. And that hammering has disproportionately affected the poorer, mainly northern, councils with the highest mortality rates. The councils with the highest death rates had the highest cuts in revenue support grant.

Few councils have seriously risen to the ‘health in all policies’ challenge. The idea of health impact statements in all policy documents is seen as bureaucratic.

We are seeing rises in suicide rates associated with economic decline. The movement in policy has been to exacerbate public health inequality – less invested in early years, adolescent health and jobs, workplace health and in reducing income inequalities. The only area in which we may see a genuine capacity for councils to improve health is through their commitments and interest in healthy town planning and the housing improvement agenda.

FPH would like to see whole council expenditure shift towards health improvement. Few types of council have seriously risen to the ‘health in all policies’ challenge. Some councils are looking to use the housing revenue account towards healthy repairs and warm homes, to use the roads maintenance budgets to reduce deaths and disability to pedestrians, or develop the health outcomes achieved through leisure services.

However, the idea of health impact statements in all council policy documents is seen as a bureaucratic imposition on hard-pressed officers. The big prize will not only be to commit the ringfenced funds wisely, but to commit to health improvement in all council spend.

  • This article was first published by the Local Government Chronicle
  • by Peter Sheridan, Registrar, FPH

The Faculty of Public Health (FPH) provides advice to employers and others on appointments procedures for senior public health posts at consultant level in the UK. Public health consultants work to promote healthy lifestyles, prevent disease, protect and improve general health and improve healthcare services.

They work across the spectrum from a rural community to the global population. Some consultants become experts in a specific area of public health, while others find that their job incorporates a cross-section of public health activities and research. It is this broad spectrum of background that can make it difficult to assess which consultant is the best fit for any particular role.

Consultants are required to have a broad understanding of all the factors that contribute to health, including the structure of healthcare systems and services, current government policy and how to interpret available data effectively. They need to be skilled at evaluating evidence to devise and implement strategies for improving and protecting health, and health services. They must be able to work on multiple projects at the same time, and be able to respond to emergencies.

Tough negotiation skills and good powers of persuasion are critical attributes. The consultant in public health has to be qualified as a public health specialist and on the GMC, GDC or UKPHR specialist register. They are also required to undertake CPD and revalidation to ensure they remain on the relevant specialist register and licenced to practice (where appropriate). This means that the consultant is qualified to FPH standards and formally regulated, including procedures to identify fitness to practise and apply sanctions if necessary.

FPH provides external professional assessment and advice, through its network of regional Faculty Advisers and FPH assessors who sit on appointment panels. The panels deliver the assurance that public health consultants have the necessary technical and professional skills required to promote, improve and protect health and provide high level, credible, peer-to-peer advice to the NHS about public health in relation to health services. This is based on the Faculty’s knowledge of training, professional development and standards and its ability to provide independent assessment and advice to local authorities on these issues.

FPH has worked with the Local Government Association, Public Health England (PHE) and Association of Directors of Public Health to provide local authorities with guidance on appointments of Directors of Public Health (links to pdf) and Consultants in Public Health (links to pdf).  This builds on the NHS process and ensures that there is senior professional input into selection with a senior PHE consultant and an assessor appointed by FPH.  We now have around 160 assessors trained in the last three years in Birmingham, London and Manchester and we now give them feedback on their contribution to the selection process.  We also do individual matching of assessors to particular types of post.

Many local authorities are maintaining the links to NHS terms and conditions (T&C) with posts advertised on medical consultant T&C or Agenda for Change (AfC) band 8d. This provides some equity with PHE and NHS posts.  Some authorities are moving to their own salary scales for new staff and some even restructuring existing staff.  These salaries can be significantly lower than what NHS was paying for a consultant in public health.

Those councils who have tried to recruit at lower rates of pay have not been particularly successful and have re-advertised at higher rates offering “market supplements”. We know that PHE are able to appoint to nearly all advertised posts but significantly fewer local authority appointments are successful. There is a demand for interim consultants across the country and I am turning down offers of up to £700 per day.  So I can see consultants moving on if they see their salaries cut either to a more enlightened authority or to NHS posts at Band8d or higher.

This has been the local authority response to equal pay challenges which have proved very expensive.  So James Gore, Head of Professional Standards at FPH, and I have been working again with our partners in LGA, PHE and ADPH to describe multidisciplinary teams in local authorities.  This has offered national guidance on how to address issues around equal pay, some encouragement to accept continuity of service and explains that a public health team will contain a range of specialists including those from a medical background. 

Medicine is the background of most of our members and half of our registrars.  It is important that medical public health consultants are not pressed into posts in PHE or NHS.  Their experience in local authorities will equip them to join the next cadre of Directors of Public Health (DsPH) and provide leadership of the public health system.  I work for PHE in Wellington House, where nearly all the consultants are former DsPH.  I believe it is important that they continue to be drawn from the field.

We need to start the conversation about retaining equity for AfC remunerated consultants who reach the top of scale.  If they take a DPH route they are rewarded with Band 9 or Very Senior Manager (VSM) pay or local authority equivalent scale.  This new guidance restates the FPH position that the AfC equivalent of medical consultant is band 8d/9.  I think we will need some additional items in the job description such as educational supervisor, Faculty assessor, and formal deputy director role.

James and I are continuing to meet with this group to take forward some of this thinking and monitor its implementation over coming months.

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