Better Health For All

• by Joanna Luxmore-Brown, Tobacco Control Manager, Sandwell Metropolitan Borough Council and

• Dr John Middleton Vice President Faculty of Public Health, director of Public Health Sandwell  (pictured below)

As responsibility for the promotion of public health in England returns to local authority control the appropriateness of investment in tobacco companies by Local Government Pension Scheme funds is increasingly being questioned (1) . The  issue  highlights  important  implications for world health, arising  from an apparently insular matter in one country.

Recently, the British Medical Journal reported that 68 of the 78 local authority pension funds in England had direct investments in the tobacco industry, worth £1.64bn. When investments through pooled funds are taken into account, all 78 are likely to have some money wrapped up in the industry (2).

Health bodies have long called for local authority pension funds to divest themselves of their tobacco companies. English Local Authorities are now responsible for taking the lead in protecting health.  It is now the responsibility of the town hall, not just the local hospital, to provide anti-smoking services.

Investing in the tobacco industry is a clear conflict of interest. The UK Faculty of Public Health believes “It is “untenable” for local authorities to be the “champion of improving public health, at the same time as profiting from tobacco.” (3)

English Councils believe that their fiduciary duty, as interpreted from case law, instructs them to obtain the best financial return for their members, regardless of ethics (3).  However, the phrase ‘duty to maximise return’ does not appear in any UK statute or case law.

Pension fund trustees have a fiduciary duty to invest “in the best interests of members and beneficiaries.” This is based on the common law duty of loyalty, which exists to ensure that trustees avoid conflicts of interest and do not abuse their position to further their own ends. (4)

A survey by The Times of local councils which administer the pension funds and are responsible for helping to set investment principles for external fund managers, found that some were reviewing their tobacco investments and were taking legal advice (3).

To date, only Newcastle City Council has pledged to end its pension fund’s investment in tobacco firms, arguing such investment is incompatible with the council’s new responsibility for public health.

The English Local Authority Pension Fund Forum, which represents 55 local government pension funds, favours a long-term investment approach that encourages environmental as well as financial returns. It has not previously advised its members on tobacco investments, but has said that it is gathering information on the subject.

Industry figures warn decisions on local government pension scheme investment in tobacco cannot be driven by public policy concern and must be considered in isolation from public policy aims.

Industry analysts have differing opinions regarding tobacco investments. Some consider tobacco stocks a good investment, particularly during difficult economic times. Shares in British American Tobacco have risen by 433 per cent over the past decade. Imperial Tobacco has enjoyed a 188 per cent rise in its shares over the same period. In comparison, the FTSE 100 has risen by 70 per cent.

Cigarette sales are being maintained through a buoyant Far Eastern market (5).  The profitability of cigarette sales in growing markets is higher to the company and the efficiency of production means that the net costs of cigarette production continues to fall.  Cigarette production has fallen in Western Europe and been replaced by Eastern European and Far Eastern production (6).

As a share investment therefore, Big Tobacco continues to look favourable in the short term.  Other fund managers recognise that smoking could disappear entirely with tougher regulations, higher taxes sales and falling sales, and therefore question whether tobacco is a prudent long term investment.

The United Kingdom is a signatory of the World Health Organisation Framework Convention on Tobacco Control (WHOFCTC) (7). This was developed in response to the globalisation of the tobacco epidemic and is an evidence-based treaty that reaffirms the right of all people to the highest standard of health.

The Convention represents a milestone for the promotion of public health and provides new legal dimensions for international health cooperation.

The right to the highest standard of living will not be achieved if pension funds continue to take the blood money of tobacco investment and their members don’t live to see the benefit.

The interpretation of the Pension fund trustees’ fiduciary duty to invest “in the best interests of members and beneficiaries” is a key one. If pension funds seek to maximise income through tobacco investment, they are promoting a strong tobacco industry. Pension fund members are council workers, many of whom will be smokers; and many  will not live to see their pensions. So promoting a strong tobacco industry can hardly be seen to be in the best interests of English pension fund members.

On a global scale, pension fund and other investments in tobacco by the developed world present a perverse form of neo-colonialism – the growing export of addiction, disease and death to developing world markets with little tobacco control, profiting the wealthy, punishing the poor individuals and countries that can ill afford it.   International disinvestment in tobacco companies is needed as part of the overall international fight to eliminate tobacco-related disease and death.

Sources:

(1) Local authority pension funds and investments in the tobacco industry

(2) Gornall, J (2013). Public health staff will have pensions invested in tobacco under transfer to local government schemes. BMJ 2013; 346:f680

(3) Ralph A. New role may force councils to quit investing in tobacco.

(4) Action on smoking and Health. The case for local action on smoking 

(5) Ralph A: (£) Asian sales keep the fires burning under British American Tobacco.

(6) World Tobacco atlas. Who is getting the money spent on cigarettes?

(7) World Health Organisation Framework Convention on Tobacco Control

By Dr John Middleton

• Director of Public Health for Sandwell, West Midlands

• Vice president UK Faculty of Public Health

• Twitter: @doctorblooz

Dr Feelgood was the first band I knew before they were famous, before I bought the album that got them to number one.  I did a support to Wilko Johnson at the Dog and Trumpet in Coventry in 1983. Our band does a passable  ‘Down to the doctors’. The outstanding rockumentary  ‘Oil City Confidential’ sparkles with Wilko’s anarchic narration.

So Wilko’s recent interview for Front Row was a bitter-sweet moment for me, another occasional collision of my personal and professional lives: the blues and public health.   For the maestro of blues machine-gun guitar, the Canvey Island rocker, the blues legend of the Thames Delta was describing his reaction to being diagnosed with pancreatic cancer.

The cancer was inoperable. The specialist told him he had 9 or 10 months to live. With a carefree chuckle Wilco said: ‘with chemotherapy he might stretch it out to a year’.

Rejecting chemo and embarking on a farewell tour, his reaction to his condition was one of feeling ‘vividly alive, an elation of the spirit. Why didn’t I work this out before?’  The question he wanted the specialist to answer was ‘How long am I going to feel like this? If the cancer kicks in, I can’t go on stage – I don’t want to present a sorry spectacle’.

Wilko didn’t know it perhaps, but what he was describing in his predicament was the time trade-off analysis – enshrined in the reviled technocratic calculation of life and death, the Quality Adjusted Life Year, the ‘QALY’.

Bureaucrats, scientists and politicians pretend it is dispassionate. It contains the subjective value judgements of people who have been asked to say how much ‘normal’ life they would trade for different states of disease and disability, and by implication how much more value a treatment might have which preserves ‘normal’ life.

For health systems, the QALY makes decisions explicit and enables society to compare different treatments for different conditions.  If money is spent on one patient it simply isn’t there to spend on another treatment which may be of more value to more people in terms of quality and length of life.

All health systems make these judgements – better to be an explicit rationing decision of government than a back-door, small-print insurance underwriter’s ruling.

The QALY can appear cold – a statistic with the tears washed off – but it embodies the pain or survival decisions individuals and their doctors need to reach. There are other considerations – risk and benefit, for instance.  All powerful treatments carry risks; all drugs are poisons. The difference between the drug and the poison is the dose – the drug may work, but the side effect may kill.

In Wilko’s case the two months’ extra life gained might just be spent in a hospital bed.  The side effects of some of the poisons are severe – a longer life with severe diarrhoea perhaps? Or a greatly shortened life through overwhelming blood poisoning?  Life-saving wonder drugs are not all they seem.

Is ‘end of life care’ spent in a hospital bed always the best choice?

Over 300 public health specialists are daily involved in life and death decisions on end of life high cost drugs. They are regularly vilified by the Daily Mail as faceless apparatchiks, denying patients their last chance of a life saving drug. NICE too, though it is the National Institute for Clinical Excellence is known only as the stopper of last-hope drugs. And yet these people are all trying to make sense of the time trade-off, and the risk-benefit, and the value of both. It is technical work but not without compassion. And yes, the family and friends test does get applied: I wouldn’t wish some of these treatments for anyone or me.

Wilko’s story personifies the public concern over too much treatment at the end of life, over-medicalisation to the detriment of the spirit. ‘The moment you are in is what matters – worrying about the future or regretting the past is a foolish waste of time.  You can’t always be threatened with imminent death but it takes that to knock a bit of sense into our heads.’

Not everyone can express it, or live it, like the artist. Some though will feel emboldened to express the same desire, to not be sucked into the deadening experience of life preservation at all costs. Not every patient wants to spend their last days in the cold clinical confines of the treatment room, when they can be experiencing the beauty of the sky or the cold breeze on their cheeks.

How much has the danse macabre of end of life treatment denied people their chance for life enhancement at a time when they most need it?  Sinking into dependency, professionally controlled, fuelled by hi-tech and Big Pharma interests? When they need to be reaffirming old friendships and loves, seeking reconciliation, redemption, elation, setting their affairs in order, saying their goodbyes?

by Dr John Middleton, Vice President, Faculty of Public Health

One of my daughters gave me a copy of How to Be a Woman for Christmas. “Every man should read it”, so the blurb goes. Yet in these musings of a contemporary Black Country wench is evidence of just how much further there is to go for women to achieve equality, rights and health. It is not just the glass ceiling that aspiring women face that should exercise us, but the gross inequalities women face in global society.

Women are more likely to be poor and in low-paid, unskilled occupations. According to the Organisation for Economic Co-operation and Development and United Nations reports at the turn of the year, women perform 66% of the world’s work, produce half the food, earn 10% of the income and own 1% of the property. Women’s educational achievement will be at least as good as men’s but they are far less likely to have opportunities for advancement generation on generation, mother to daughter.

Over Christmas, “Victorian” has been much in evidence as a descriptor of UK public health – whether in relation to the rise in tuberculosis, the gin-factory fire in Sandwell, soup kitchens, rough sleepers and the undeserving poor. “Biblical” has been used to describe the unfolding horror and public health disaster of Syria. “Dark ages” has been used to describe the carnage of Newtown, the massacre of polio vaccination workers and the gang rape of Delhi.

In the field of crime it should be obvious that blaming the victim is unacceptable, and yet it goes on: the school didn’t protect itself; the rape victim was wrongly dressed. In public health the powerful and comfortable are renewing their assault on the victims of their health-destroying policies: John Redwood says the poor are to blame for the growth of betting shops; David Cameron praises the food-bank operators for their contribution to ‘Big Society’ rather than confess his shame for returning a civilised country to intolerable poverty.

In public health too we need to condemn victim-blaming and advocate for the health of the most vulnerable. Championing the health and rights of women and children in the early years is a key component of that.

The problem with the poor is poverty. The problems of violence and the problems of ill health are rooted in inequalities in opportunity and money between social groups, between geographical areas and between the sexes.

The North West Public Health Observatory in its tour-de-force report Protecting People, Promoting Health shows just what a massive public health problem violence is and gives us a public health approach to evidence to reducing it. It’s a Marmot report for violence-prevention and demonstrates how crucial early-years interventions and youth support are to reducing crime and violence.

But as well as its careful analysis of interventions which set the conditions for better health and positive, peaceful relations in communities, it also sets out a chapter on making behaviours which condone or encourage violence unacceptable. It is not women who are committing gang rape, it is not women who are off-loading barrel bombs from helicopters in Syria, and it is not women are gunning children down in US schools. But it is also not women who are determining the policies which are bringing about the impoverishment and bankruptcy of our nation and the next generation.

We in the public health community have been preoccupied with our own position in the NHS break up. I make no apology for that in the work of FPH – if we weren’t doing that no-one else was going to. But, as we look forward, it is time to look outwards, to re-establish our role as advocates for the health of the public. The health of the UK has not faced such a formidable threat for many years. The systematic impoverishment of the poorest, most disabled and most vulnerable is accelerating and will be given further thrusts in April and in October as the benefits cuts hit harder. Combining this with a fragmented and weakened health system, who will be there to hear the calls?

Educate a woman and you educate a village is as true for a UK housing estate family centre as it is for an African village.

And it’s as true for our national corporations, governments and institutions. As a new man fills another junior minister role, it appears there will be little new education in the Cabinet village.

In the new-year press, Professor Athene Donald continued her eloquent championing of the need for more girls to go into sciences. Looking for a happy new year for my daughters and granddaughters, and all our daughters and granddaughters, it is clear we need some fundamental power shifts. The public health specialty is well placed to demonstrate the greater involvement of women in all disciplines, and at the highest levels.

But in our advocacy for the public’s health, we must strive for greater equality for women, for the health of our national and the global village.

John Middleton, Vice President (Policy)

Part Two: benefits of Health and Wellbeing Boards and risks to health protection

Dr John Middleton (pictured above), Vice-President of the UK Faculty of Public Health and director of public health for Sandwell in the West Midlands, gave evidence to the Communities and Local Government Committee on the role of Local Authorities in health issues on Wednesday 21 November 2012. This is the second part of two blogs based on an edited version of his evidence.

In moving into local authorities, [local authority staff] won’t know what they don’t know [about public health], and the need for the senior public health person to be at the chief officer’s table reporting to the chief executive is absolutely essential.  Directors of public health need standards, resources and powers.

One of the aspects of these reforms that worries me and some of my colleagues is the notion of assurance — that we will somehow float over the whole system and say it is all okay.  Is it a warm glow you feel when the hospital tells you it is doing the right thing, or is it a critical inspection of what is going on, be it in infection control, screening or any of the other areas?  Directors of public health need to have both the resource and the power to deliver those.

As to standards, councils are used to working in a peer-led environment with sector-led improvement.  The Faculty of Public Health is keen to support that process.  The whole system needs to work at a sufficient level.  If I as a local authority officer find that the neighbours are not doing as well as they need to on TB, genitourinary medicine or drug control, those problems are my problems too.  If I have a wonderful town planning service that does safe walking and cycling and those routes stop at the border, we will not get the best for public health, so we need standards across authorities.

I have … very little confidence in what I have heard described in relation to screening, immunisation and emergency planning around the NHS Commissioning Board.  The screening and immunisation staff we have trained and developed in Sandwell to work on a daily basis are destined for Public Health England. They will be seconded to the National Health Service Commissioning Board and managed by heads of public health commissioning with no qualification in public health, necessarily.  You would not invent that system were it not for the extraordinary difficulties that the health reforms put us in.

As to health protection, we need to emphasise that there is a whole preventive infrastructure in place in local authorities, but there has been a very successful infrastructure for infection control in primary care trusts.  The district infection prevention control officers have an excellent story of reducing healthcare-acquired infection.  These are not things where the Health Protection Agency historically has done a great deal of hands-on work. These are ecological problems.

If pharmacists prescribe loperamide, GPs prescribe antibiotics, care homes do not clean their mattresses more than once every 15 years and hospitals do not record the data on clostridium difficile, potentially these send infections spiralling around our communities, and we need to be able to see that preventive work carried on in local authorities.

All of the evidence suggests that mortality is strongly related to deprivation. The problem is that, when you look at what is in the ring-fenced budget, it is not about premature mortality; it is about genitourinary medicine services, school nursing and drugs and alcohol services.  We have used one formula potentially to describe a totally different set of problems and answers that we need.

If we simply reallocate the pot [of funding] we have, we will disadvantage those who have spent more against their level of need now.  As we have with health service allocations in the past, my understanding is that we using the formula to decide whether to move people.  There are other real problems with the ring-fenced budget not specific to the ring-fence: we are talking about an investment of £2.2 billion, and the risks around genitourinary (GU) medicine, which is growing by 3% or 4% a year.  For my PCT an extra £400,000 a year was nothing out of £500 million, but my local authority is extremely concerned about £400,000 out of £20 million.  This is an area of risk that local authorities are very concerned about.  In Westminster two-thirds of the budget goes on the GU medicine service, and they could spend all of the ring-fence in a very short space of time with those increases in activity.

Health and wellbeing boards are being embraced.  They have the benefit of having some continuity with the health and wellbeing boards that have been in place since 2007 in many cases.  They also have the benefit of being the least prescribed part of the Health and Social Care Act.  There is a lot of scope for local determination of what they look like.  They also have the benefit that they are the glue; they are the central point.  They are the only coherent part for many local authorities, and they are the engine room through which health strategy can be delivered.  It is a body we need to support and develop.

In Sandwell it is chaired by the leader of the council, and that top-level seriousness that is going into the health and wellbeing board is extremely crucial.  We have seen it at least as a meeting of commissioners; it is not yet a commissioning body, but we will need to pool more budgets potentially, not fewer.  We will certainly need to share our parallel investments in alcohol, drugs and so on, and it is a forum we want to support.

An additional positive is that that commissioning for drug and alcohol misuse, vulnerable young people and so on is coming into the local authority through public health. It is an opportunity to bring the safeguarding of children closer to a public health agenda.  In dealing with issues like domestic violence and new migrant populations there is a chance of a more co ordinated approach by local authorities, but the overall issue of eight separate commissioners is a problem.  The NHS Commissioning Board doing the nought to fives until 2015-16 suggests that we do not trust local authorities with that kind of commissioning, and that is a mistake.

Moving public health is not supposed to make things easier;
it is supposed to make them better.

Dr John Middleton (left), Vice-President of the UK Faculty of Public Health and director of public health for Sandwell, gave evidence to the Communities and Local Government Committee on the role of Local Authorities in health issues on 21 November 2012. This is the first of two blogs of an edited version of his evidence.

Our view about the significance of the transfer of the role back to local councils is that we would certainly want to see health as an issue of civic pride for councillors.  It should be unacceptable if life expectancy is not as good as it is in other parts of the country.  The issue is to get councils to appreciate health as a matter of civic pride and necessity and what they should expect for their citizens.

“There are large chunks of the system that are in flux and are still being devised and determined, and there are considerable risks in that.  As to what councils need to do, we describe three domains of public health: health protection, which is about keeping us safe from infectious disease, communicable disease and major emergencies; health improvement, which is all the policies of the council and how we promote health and keep people healthy; and the domain of healthcare-related public health, where the analysis of what goes on in your local acute hospital is every bit as important as those other two elements.

If councils are to be strategic leaders of the health strategy, they will have to be able to understand and challenge what goes on in the hospital on their behalf.  Similarly, they will have to be able to support clinical commissioning groups by providing public health advice so that what goes on in primary care can be as effective as we would advise.

“The position of many public health staff is still not determined.  There is a programme through which migration to local authority public health and the NHS Commissioning Board is laid out, but there are still many people who have not yet been aligned.  There is still a due diligence process to be gone through in councils.  There are posts, for instance, in policy analysis, community development and certain other areas where councillors will say, “We already do that, thank you.”

There is considerable risk and uncertainty for public health staff.  Potentially, there will be 50 vacant directors of public health posts by April next year according to the ADPH survey.  We are seeing a loss of public health staff through the recent mutually agreed resignation scheme.  In my own district of Sandwell we have lost one third of our public health workforce in the last two months.

It is a period of serious risk and uncertainty.  I think that we will come through it positively. The cadre of trainees in specialist positions is an excellent and outstanding bunch of people and they will graduate through the ranks, but there will be a very uncomfortable period when a large number of vacancies for directors of public health in particular is the reality. A real risk is that people who do not have leadership in public health do not value it and do not see what it is going to do for them.

Health is political, and arguably the reform that moves public health practitioners into the local authority should harness and make a positive out of that.  I am not naïve enough to think there will not be difficulties about it. Nevertheless, the best practitioners and managers will harness the political interest to the best benefit for the public’s health.

There are concerns in relation to the different cultures.  Evidence base is not necessarily a political concept.  Nevertheless, we all need to learn from it and increase the quality of decision making.  Moving public health is not supposed to make things easier; it is supposed to make them better.

Written by: Mark Weiss, FPH Policy Officer

‘Advocates for Challenge’ – Public Health from Evidence to Action

Firmly embracing the theme of the FPH Annual Conference 2012 – Looking to the Future, Building on the Past – Welsh Minister for Health and Social Services, Lesley Griffiths AM, warmly welcomed delegates to Cardiff, and recalled the seminal work of Julian Tudar Hart who some four decades ago proposed the Inverse care Law principle of inequity.

Hart’s premise was that the availability of good medical care varies inversely with population need – and operates more completely where medical care is exposed to market forces. It rings as true today as it did then. Through this prism of health inequalities, the Minister declared her firm commitment to tackling the social determinants of health, informed by the best available evidence and with the support of the public health community – a community Griffiths views as ‘advocates for challenge’.

And while the challenges confronting Wales are broad, the Minister affirmed that the Welsh Government is addressing them robustly.  The five year vision for the NHS, Together for Health, has made a commitment to service modernisation; addressing health inequalities; developing better IT systems and an improved information strategy; improving the quality of care; workforce development; instigating a ‘compact with the public’; and introducing a changed financial regime.

Building on this encouraging work, Griffiths stated her dedication to a cross-governmental approach to public health (and against inequity) as integral to her agenda – not least on the reduction of child poverty. The ‘Flying Start Programme’, bringing together education, childcare, health and social services and the voluntary, private and statutory sectors to offer preventative interventions is a solid example of partnership working. The CMO, PHO and Public Health Wales all firmly support this initiative.

Echoing outgoing CMO Tony Jewell, who in his Annual Report 2011 set out the ‘stark challenge’ of inequalities, and the threat of non-communicable disease, the Minister stressed the need for a consensus on action on public health and sustainability.  Griffiths identified several key threats in the CMO’s report, including alcohol, obesity and blood borne viruses (in particular Hepatitis b and c) – all exacerbating the life expectancy gap in Wales.

Addressing these issues requires solid evidence, and Griffiths underscored the ‘big role’ public health has to play informing this evidence which is listened to by Government. With real potential to effect far reaching policy change and a tangible impact in those areas where it matters the most, the work of Directors of Public Health and their annual reports, Public Health Wales and the wider public health workforce are, Griffiths stressed, essential to the development of a common vision.