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  • 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.

  • By Dr Jayne Hutchinson
  • Research Fellow
  • University of York

Active travel, defined as walking and cycling short journeys such as visiting friends, commuting or going to the shops, is high on the policy agenda. In 2010 the Departments of Transport and Health published a joint strategy on active travel and many local authorities have now published their own active travel policies.

Inner city cycling

Active travel: getting more active and healthy

Active travel simultaneously tackles two of society’s big challenges: more sedentary lives and the health concerns associated with that, and environmental changes caused by burning fossil fuels.  Yet, the understanding about its social patterning is limited, particularly in relational to differences in socio-demographic predictors of active travel between urban and rural residents. Understanding variations between rural and urban populations may help local governments to devise policies that are appropriate and tailored to their communities.

Here at the ESRC-funded HOPE project (Health of Populations and Ecosystems) we have undertaken an initial analysis of the active travel of adults using data collected from Understanding Society, the largest UK representative household panel study.

In urban areas (defined as settlements of 10,000 people or more) we found that:
•    Residents were 64 per cent more likely to report that they always or very often walked or cycled short journeys of less than two to three miles.
•    Residents not in full-time employment and with no children are likely to walk or cycle more.
•    High-earners were less likely to take opportunities to travel actively, particularly if they had children, although those educated to degree-level were more likely to cycle or walk short journeys.
In rural areas, we found that:
•    Only seven per cent of the population reported not having a car in their household.
•    There were fewer socio-demographic predictors of walking or cycling short journeys.
•    Rural residents in both higher and lower income brackets tended to use their cars for shorter journeys regardless of education or whether they had children or not.

Although there are fewer opportunities for active travel for rural residents  than for those living in towns and cities, the habit of using cars even for short rural journeys should be challenged. People living in rural areas need to be more pro-active than urban residents in order to meet their physical activity recommendations and to reduce their carbon footprint.

There also seems scope for increasing active travel in urban areas for some groups of people such as women, those with children, or with lower qualifications. We know that people with lower qualifications and lower income are less likely to engage in vigorous active leisure pursuits than those in higher brackets, therefore encouraging more active travel for some could be an important factor in helping increase their everyday physical activity.

In the next phase of this research we will explore relationships between people’s environmental behaviours such active travel, energy use in the home and health behaviours such as fruit and vegetable intake, alcohol and smoking. An understanding of this may influence policies for improving the health of the population and the health of the environment.  

Signatories:

  • Dr Ben Bouquet
  • Dr John Ashton
  • Prof. Amanda Burls
  • Prof. Simon Capewell
  • Sir Iain Chalmers
  • Dr John Middleton

In public health, there is a tendency to focus on numbers and statistics, which can detract from deeper understanding of the human stories involved.  To date, in excess of 1,400 Palestinians have been killed in Israel’s bombing of the Gaza strip.  Around one in five is a child.  The vast majority are civilians.  To date 56 Israeli soldiers have died and three civilians have been killed in Israel (1).

We need all sides in this conflict to work for peace. All forms of aggression, whether they are carried out in the name of Israelis or Palestinians, are harmful to the public health of people living in both countries.

Israel, as an occupying power in Gaza and the West Bank, has a number of legal and moral duties, which include the safeguarding and promotion of public health for the Palestinian population (2). In this regard it has undoubtedly failed.

The blockade of Gaza since 2006/7 has restricted supplies of food, fuel and the materials needed to rebuild communities following previous destruction.  This and the government’s dire financial situation are contributing to massive unemployment, which remains consistently in excess of 30%.

The government’s lack of funds and severe fuel shortages have precipitated a worrying sewage crisis, with raw sewage now passing into the Mediterranean and increasing greatly the risk of outbreaks of infectious disease.  Fresh water supplies have also been compromised and 90% of water supplies are unfit to drink.  Many households are now reliant on bottled water for drinking.

At least 140,000 dunums of land planted with fruit and vegetables are at risk of drought.  The effects on health services from the fuel shortage, the limited supply of medicines and medical equipment and damage from recent bombing are of grave concern (3).

The cause of the present extreme deprivation in Gaza is the Israeli blockade, compounded by the closure of tunnel trade with Egypt, for so long an economic lifeline.   It is in this context that the recent clashes have arisen: many Palestinians do not see any realistic route to achieve restoration and improvement of their daily conditions.They have a shrinking means to protest, to ask the world to listen to their pleas for the reinstatement of their dignity and their autonomy (4).

In the current conflict, there have been allegations of the deliberate targeting of hospitals and civilians (5). Recent reports indicate extensive damage to the health service infrastructure, including hospitals and primary care clinics (6).

The main power plant has been hit which is now further affecting the water supply. Paramedics have been unable to access civilian casualties and lack a safe passage out of conflict areas.  Similarly there is no agreed safe zone for civilians and shelters and two UN schools have been hit.  (7)

In a video seminar with London public health specialty registrars this week Mahmoud Daher of the World Health Organisation in Gaza, described the current conditions, his sleep deprivation amid the sounds of the bombing, and the difficulty of comforting his children in these extreme circumstances.  He stated:

“The international community is suffering from a deficiency of conscience.  The killing of children and targeting hospitals has become a matter of numbers and incidents to report. A state of desensitization to the human aspect of this will be dangerous on humanity, we only see numbers, but there is a story behind each number, a human being. I witnessed today a targeting of the outside wall of Shifa hospital; I was there, about 15 meters from the wall. A few minutes after a bigger bombardment was heard and children arrived – dead bodies to the emergency room of Shifa, that was horrible. 8 children and 2 adults were killed while they were playing in the playground at Shati refugee camp. Can anyone in this world explain why? They are not numbers.”

The public health community has a strong tradition of seeking to save lives and prevent suffering, to analyse the root causes of inequalities and propose solutions, to follow non-violent codes of conduct that transcend narrow political and factional divides and support the cause of common humanity.  We invite the public health community to acknowledge and make links with Palestinian and Israeli human rights and health organisations and to support them in their work (8). We echo these organisations in calling for the following actions:

  • Cease the bombardment of inhabited homes, neighbourhoods and areas in the Gaza Strip (9).
  • Open a safe route for civilians to escape the battle zone and declare a safe shelter zone in the Gaza Strip (7).
  • Ensure the adequate provision of immediate medical and humanitarian assistance to the people of Gaza to ameliorate the consequences of the massive destruction of homes and infrastructure.

There have been calls for consumer and academic and cultural boycotts of the kind seen during Apartheid South Africa and with French nuclear testing in the Pacific.  We call on the international community, including our own government, to implement an arms embargo on Israel and Israel must abide by international law under the conventions it has ratified.

We urge those with influence in the Israeli government to speak out and to call for unconditional and meaningful talks with the Palestinian coalition government.   In this call they are supported across the world in their effort to end conflict and to reach a peace in which all parties can live with dignity, autonomy and freedom from aggression and intimidation.

We express our sympathy with the friends, families and loved ones of all those who have been killed.  Peace is possible, and it starts with talking.  As Nelson Mandela said, “If you want to make peace with your enemy, you have to work with your enemy.  Then he becomes your partner.”

References:

(1) Burke J. (31st July 2014). Gaza ‘faces precipice’ as death toll passes 1,400. The Guardian

(2) Occupation and international humanitarian law: questions and answers (2004).  The International Committee of the Red Cross

(3) Gilbert M. (June 2014) (links to a pdf) Brief report to UNRWA:The Gaza Health Sector as of June 2014.  University Hospital of North Norway

(4) Manduca P., Chalmers I., Summerfield D., Gilbert M., Ang S. and more than 20,000 signatories (23rd July 2014).  An open letter for the people in Gaza.  The Lancet.

(5) Dr Mads Gilbert in an interview with Rania Khalek (23rd July 2014).

(6) Israeli fire kills nineteen in Gaza UN school (31st July 2014).  Al Jazeera

(7) Mahmoud Daher (WHO), direct reporting.

(8) Laub K., Goldenberg T. (28th July 2014).  Gaza’s Al-Shifa Hospital Compound, Nearby Park Hit In Attack. The World Post (a partnership of the Huffington Post and Berggruen Institute on Governance)
(9) Sherwood H. (30th July 2014).  Gaza’s only power plant destroyed in Israel’s most intense air strike yet.  The Guardian

(10) 11 Israeli HR Organizations urgent call: Open a safe route for civilians to escape the battle zone and declare a safe shelter zone in the Gaza Strip (25th July 2014)

(11) Sherwood H. (30th July 2014).  Gaza: at least 15 killed and 90 injured as another UN school is hit.  The Guardian

(12) The eleven Israeli organisations which recently called to open a safe route for civilians to escape the battle zone and declare a safe shelter zone in the Gaza Strip are:

-    Adalah – The Legal Center for Arab Minority Rights in Israel
–    Association for Civil Rights in Israel
–    Bimkom – Planners for Planning Rights
–    B’Tselem – The Israeli Information Center for Human Rights in the Occupied Territories
–    Gisha – Legal Center for Freedom of Movement
–    HaMoked – Center for the Defence of the Individual
–    Machsom Watch
–    Physicians for Human Rights – Israel
–    Public Committee Against Torture in Israel
–    Rabbis for Human Rights
–    Yesh Din – Volunteers for Human Rights

(13)  B’Tselem calls on the Government of Israel to immediately cease the bombardment of inhabited homes, neighborhoods and areas in the Gaza Strip (21st July 2014)

  • Dr Veena C Rodrigues
  • Clinical Senior Lecturer and Head of Year 3 MBBS
  • Norwich Medical School

I have only recently made the transition from ‘lurker’ to ‘active user’ on Twitter. Recently, I found myself following a talk by Dr Jeremy Farrar, Director of the Wellcome Trust via live-tweets from a London meeting for clinician scientists in training (Nurturing the next generation of medical researchers). Dr Farrar cited three challenges to UK science:

(1)    bringing young people into science and finding ways to keep them there;
(2)    addressing the divide between the clinical and research communities and encouraging them to work together; and
(3)    tackling the damaging separation of PH from clinical service delivery.

As a clinical academic in public health medicine (PHM), the last two points resonated strongly with me.  I have held joint academic-service roles in PHM right through specialty training and into my Consultant role. Core to such a role was the need to bridge the gap between academia and the service setting, not only to work efficiently and flexibly across the two, but also to ensure that the skill set developed and enhanced in one role was utilised clearly to benefit the other.

In my case, my clinical academic skills of research methodology, critical appraisal and evidence-based medicine were ideally suited to needs assessments, priority-setting, service specification and clinical policy development, clinical engagement with provider Trusts, evaluation of cost-effectiveness of services at my Primary Care Trust (NHS) employment.

Similarly, my local service provision experiences enabled me to pull out of my tool box examples and anecdotes to liven up any teaching/ training sessions in my educator role. You must remember we are talking about integrating PHM into undergraduate medical education, which is a daunting challenge: ask any UK medical school public health educator! I also had first-hand knowledge and experience of the service setting to inform the writing of research proposals to apply for grant funding, etc.

It is easy to assume that clinicians and scientists would work together naturally but at a time when healthcare provider organisations face increasing scrutiny in terms of meeting targets for service provision, service priorities often trump teaching and research. Addressing this widening divide in the face of conflicting organisational priorities is likely to be challenging but crucial for nurturing the next generation of medical researchers.

The NHS reorganisation following the Health and Social Care Act 2012 resulted in public health departments being moved out of the NHS and into local authorities (LAs). While the advantage of joint working between public health and local authorities to improve and protect the health of the population cannot be underestimated, the benefit of this conscious coupling to local clinical service delivery is much harder to visualise.

Relationships that had been built after years of committed and painstaking nurturing of the clinician/provider-commissioner relationships through clinical dialogue facilitated or led by PH specialists were suddenly stripped away resulting in another layer of bureaucracy (albeit with a ‘core offer’) diluting the relationships between the two organisations (1).

The public health emphasis on health needs assessment, priority setting, fairness, equity, appropriate and effective commissioning in the face of budget restraints. Monitoring and evaluation of services is likely to vary in breadth and depth across the country. It is dependent on whether local authorities have kept local structures in place and the level of commitment of the local authorities to health/ clinical service delivery. A postcode lottery?

A recent publication confirmed that local authorities across England are diverting ring-fenced public health funds and scaling back staffing to plug funding shortfalls caused by government budget cuts (2). It has also been reported that despite a mandatory requirement for Health and Wellbeing Boards to provide public health advice to local clinical commissioning groups (CCGs), sufficient public health input into NHS services to is lacking. This is at a time when CCGs are struggling to balance quality improvement and financial equilibrium (3).

Following the NHS reorganisation in 2013, public health clinical academics and researchers who had honorary clinical contracts with local NHS organisations (PCTs) lost their clinical (NHS) links when the hosting of these contracts moved to PH England, a new non-NHS organisation, still struggling to establish its mark (4). This resulted in the formal separation of a link between academic and service public health that had facilitated joint working, making it nearly impossible to influence the work of local CCGs without getting embroiled in convoluted management links and processes.

So, you might well ask: where does this leave healthcare public health? It is difficult to predict the future but if the government is listening, please could you strengthen the requirement for local authorities to have an appropriately skilled public health workforce to provide adequate input into local NHS services? Supporting the work of CCGs towards effective and cost effective local health services commissioning is after all a key part of the standards for delivery of public health within local authorities! (5)

And pretty please, could you also restore public health academic-service links especially for clinical academics? I am fast running out of new examples to give my medical students to emphasize the clinical relevance of the public health curriculum.

References:

  1.   Department of Health. Guidance on the healthcare public health advice (core offer).
  2. Iacobucci G. Raiding the public health budget. BMJ 2014; 348: g2274.
  3.   Furber A. Public Health: what has worked, what hasn’t, and what’s next? The Guardian, 5th April 2014.
  4.   UK Parliamentary Health Committee. Public Health England: Eight report of session 2013-14. London: The Stationery Office Ltd, 2014.
  5. FPH. Standards for Public Health, 2013.
  • by Miranda Eeles
  • Researcher at London School of Hygiene & Tropical Medicine

“Why are we not more angry?”

That was the question being raised by the participants of Sandwell Health’s Other Economic Summit (SHOES) which brought together academia, doctors, architects, journalists, local government and civil society to discuss issues ranging from sustainable food policy and climate change to the privatization of the NHS.

The Summit, which was held at the Balaji Temple in Tividale on Friday 28th March, is Sandwell Health’s annual event that aims to explore current themes and challenges in public health both at global and local level.

Neo-liberalism, corporate power and an assumption that development equals economic growth were identified as some of the mains reasons behind the problems facing the world today, and the increasing gap in inequalities.

“We need to change the narrative”, said Dr David McCoy, senior clinical lecturer at Queen Mary University, London and Chair of MEDACT.  “We need to demonstrate an alternative system and put forward intellectual and scientific arguments to eradicate poverty and address climate change.”

Corporations, government and the insurance industry were all put under the spotlight as speakers lamented a lack of leadership across the party spectrum.

But as in previous SHOES events, the audience also heard about the achievements at local level which illustrate how change can happen, provided the political will is there.

Urban food growing, investing in community assets and young people, creating a culture of activity and a return to a strong synergy between rural and urban environments were listed as some of the ways in which to address local needs.

This year’s Summit also was a celebration of the exemplary work done by John Middleton, Sandwell’s Director of Public Health, who retired at the end of March after 27 years in the job.

‘Dials’ and ‘levers’ were terms used to describe priorities and actions that have been employed under his leadership to bring different agencies together to improve the health and well being of the local population, including the Police, NHS Trusts, Clinical Commissioning Groups, a Youth Council and different departments of Sandwell Council.

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