Public Health Response to the Refugee Crisis in Europe: why revisiting the lessons from the Kosovo Refugee Crisis in the North West in 1999 has important lessons for 2015

  • Abdul Razzaq
  • Director of Public Health, Trafford Council, and Chair North West Directors of Public Health Network

On 7 September 2015, the Prime Minister announced a significant extension of the Vulnerable Persons Relocation Scheme for Syrian refugees. The Government intends to resettle up to 20,000 refugees from Syria’s neighbouring countries over the next five years. However, it does not intend to offer resettlement to Syrian refugees already in Europe, or to participate in the EU’s proposed refugee resettlement and relocation schemes.

A joint statement from ADPH and FPH regarding the current crisis and recommendations for action can be found via here

1.    Public Health Response – Revisiting the Lessons from the Kosovo Refugee Crisis in the North West

The unstable political situation in the former Yugoslavia resulted in inter-ethnic conflict with profound economic, social and human rights consequences. It led to a major military intervention by North Atlantic Treaty Organisation (NATO) forces. A large proportion of the Kosovars were forced to abandon their homes and seek refuge in Macedonia and Albania.

The government of Macedonia was very worried that the large number of Kosovar refugees in their country might destabilise the country’s delicate political balance. This led to pressure on the European Union countries to make adequate arrangements to admit substantial number of refugees from Kosovo into the European Union countries.

The United Kingdom government agreed to take in an unspecified number of refugees. In the event 4346, refugees were admitted into the United Kingdom under the United Nations High Commission for Refugees (UNHCR) Humanitarian Evacuation Programme. Of this total 2400 were accommodated in the North West region of the United Kingdom.

2.    Kosovan Refugees: The planning in the North West Region for reception and care of refugees

The planning for the reception and care of refugees in the North West region was led by the Health Emergency Planning Advisor (HEPA). The HEPA has very close day-to-day relationship with the EPCU and reports to the Regional Director of Public Health. The HEPA is charged with the responsibility of building and maintaining the region’s capacity and capability to respond to situations that can pose a threat to public safety and health. The HEPA is supported in his work by the Regional Epidemiologist with an expertise in communicable disease control. The HEPA also has ready access to advice on environmental hazards and in addition can readily access generic public health advice.

In their day-to-day work the HEPA has established effective links with the agencies that would have a role in emergency situations. The local authorities, the health authorities, the police, the fire service, the ambulance service, the Environment Agency, and the hospital service are among the bodies with whom the HEPA has close relationships. These relationships provided the Regional Director of Public Health and EPCU with an easy and rapid access to the main agencies that have resources to meet the health and social care needs of the refugees at the local level.

The HEPA convened meetings at a sub-regional level of the key agencies to agree a basic operational framework to cater for the needs of the refugees. These meetings highlighted important issues for agencies that are charged with service commissioning and delivery.

The plan for the North West was divided into three parts or phases:

1.    Arrangements for the initial reception of the refugees at the port of entry (Manchester Airport)
2.    Arrangements to provide care for the refugees and to integrate the refugees into the social fabric of the local communities
3.    Arrangements for the safe return of the refugees to Kosovo when the conditions for return are judged to be right by the United Kingdom government and the UNHCR.

3.    Kosovan Refugees: Arrangements for the initial reception of refugees at the port of entry (Manchester Airport)

These arrangements put in place followed discussions with the key agencies with a part to play in this phase of the operation. The most immediate concern was to ensure that the medical needs of the new arrivals were attended to, taking into account the nature and urgency of the medical need.

The HEPA had established an effective communication with a Department of Health doctor who was seconded to work with the UNHCR in Macedonia. The Department of Health doctor was able to provide the HEPA with advance information about the numbers of refugees likely to arrive on the incoming flight. In addition the HEPA was also able to obtain information from the Department of Health doctor about the medical condition of the refugees on the flight.

Arrangements were put in place to provide emergency first aid assistance to the refugees once the aircraft had touched down. An ambulance was also on standby to provide safe transfer to the local hospital. The port health staff conducted the routine screening for communicable diseases. The refugees were then transported to a civic centre (situated about a mile from the airport). The arrangements for the reception of refugees at the civic centre were put in place by Manchester City Council. The arrangements were designed to:

  • Ensure that the refugees were met in warm, cheerful and friendly surroundings
  • Ensure that access to the reception was limited to those who had an agreed and defined part to play on the day
  • Meet the immediate primary health care needs of the refugees
  • Ensure that the essential formalities were conducted in a sensitive and efficient manner
  • Ensure that the initial social and housing needs were assessed
  • Ensure that the regions voluntary sector was able to make its contribution
  • Ensure that there was no media intrusion at the reception centre
  • Ensure that the refugees were transferred from the reception centre to their initial accommodation in a safe and efficient manner.

The staff and volunteers at the reception centre were briefed about the recent history of the former Yugoslavia and the origin of the conflict leading to the Kosovors of Albanian origin becoming refugees and fleeing to Macedonia for their physical safety. It was agreed that in view of the known negative experiences of the refugees of the police and the army in Kosovo, the police numbers at the reception centre would be kept to a minimum and further, that if possible the police should provide officers not in uniform for the reception centre.

The Refugee Council ensured that interpreters were available in adequate numbers at the reception centre. Manchester Health Authority provided the reception centre with the services of general practitioners registered with it. At all times there was at least one general practitioner at the reception centre to attend to the primary health care needs of the refugees. The general practitioner was supported by a nurse. The children’s needs were accommodated by the play leaders from the Manchester City Council. The refugees on arrival at the reception centre were welcomed by a senior officer from Manchester City Council.

The refugees were then provided with a hot meal on arrival before any formalities took place. The local branches of the British Red Cross played a central part welcoming the refugees at the reception centre. They brought clothes and essential toiletries for the refugees. The local and health authorities that were designated to act as hosts for refugees arriving on specified flights brought their own officers to the reception centre. These officers used this opportunity to assess the housing, social and health care needs of the refugees. They also travelled with the refugees to their initial destination.

After each completed reception operation there was a full debriefing with the aim of incorporating any important lessons into the following reception exercises.

4.    Kosovan Refugees: Arrangements to provide care for the refugees and to integrate the refugees into the social fabric of the local communities

This part of the arrangements to some extent devolved to the local partners. A number of meetings were held with the office of the Regional Director of Public Health to ensure that the variations in practice were not undesirably uneven. The key issues that needed to be tackled at this stage are discussed below:


The key tasks for the health service sector were agreed to be:

•    Help with registering with general practitioners, dentists and opticians
•    Information about the health care system
•    Awareness raising among general practitioners and hospital consultants of cultural factors, unfamiliar conditions and medical problems arising from experiences as refugees, for example, torture and other physical abuse, rape and other forms of sexual abuse, malnutrition, exposure, shrapnel and gunshot injuries and disorders relating to possible use of chemical weapons
•    Specialist provision of practitioners experienced in treated trauma related mental health problems
•    Care of pregnant women
•    Vaccinations programmes
•    Care for children
•    Advocacy and interpreting

Each health authority had an executive officer named Director of Public Health, who advises the authority of commissioning issues. The office of the Regional Director of Public Health is closely linked to the networks of the region’s Directors of Public Health. The link enabled the Regional Director of Public Health to have a degree of influence on the actions of the health authorities in this area.


The local authorities traditionally take the lead in this area. The local authorities took steps to raise awareness of the care providers in the following areas:

•    Mental health
•    Physical disabilities
•    Sensory impairments
•    Older people
•    Learning disabilities
•    Support for carers
•    Drug, alcohol misuse

The local authorities made arrangements to enable the refugees to have access to Albanian organisations in the United Kingdom and to Albanian newspapers (these were accessed via the internet).

The local authorities also made arrangements to attend to the recreational and leisure needs of the refugees. Football matches, visits to leisure centres and visits to cinemas were arranged for those who wished to take advantage of these.


The local authorities again took the lead in making this provision. The key principles were agreed with the Refugee Council. The Refugee Council was charged with approving all the accommodation offered to the refugees. Apart from the physical condition of the properties offered to the refugees the following principles were followed:

•    The allocation practices need to be flexible
•    Housing allocation needs to take account of social networks, family size and family ties
•    Refugees may need to be clustered in some areas
•    Housing arrangements should take account of the services available in the area
•    The safety of the refugees should be taken into account when an allocation is made

The local authorities made efforts to involve the refugees in the running of the reception centres and in many instances the refugees themselves took over the running of the catering arrangements.


The key issues tackled in this area were:

•    Information for parents about education in the United Kingdom
•    Access to special needs provision as defined for the general population
•    Parent/school liaison, including interpreting
•    Awareness raising and training for schools on needs of refugee children
•    Language support
•    Awareness raising for relevant agencies on needs of refugee children

A number of other related issues may need to be addressed in the future should some of the refugees remain the United Kingdom for longer than 12 months. These relate to education and training for future employment in the United Kingdom.

Kosovan Refugees:  Arrangements for the safe return of the refugees to Kosovo when the conditions for return are judged to be right by the United Kingdom government and the UNHCR

At a UNHCR meeting in Geneva on the 12 July 1999 there was general consensus among those countries who received Kosovar refugees that the return programme should be coordinated through the UNHCR and International Organisation for Migration.

The Regional Director of Public Health was instrumental in initiating a fact finding visit to Kosovo. This visit was undertaken by the team of four experienced and high ranking officials. They produced a report that was submitted to the EPCU. The team looked at the future reconstruction and development needs of the health care system in Kosovo.


1.    Syrian Refugees and the UK – House of Commons Library http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06805

2.    Syrian Refugees and the UK. House of Commons Library – Briefing Paper Number 06805, 8 September 2015. Ben Smith and Melanie Gower.

3.    Migration pressures in Europe – House of Commons Library – http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7210

4.    Balkan briefing (part 4). Kosovo refugees in the North West region of the United Kingdom. Iqbal Sram, David Ward, Journal Epidemiology Community Health 2000;54:314-317 doi:10.1136/jech.54.4.314

  • By Dr Stephen Dorey and Dr Joanna Nurse

Prevention and public health don’t actually save money, you still have to pay for another illness later on. Even if prevention does save money it takes so long to see outcomes that it’s can’t be a priority right now.

Variations on these two statements, sadly all too commonly expressed, by ministers of health and other policy makers were the drivers for a new publication by the World Health Organisation’s regional office for Europe and developed with the support of FPH. ‘The case for investing in public health ’ attempts to dispel these myths in a format accessible to decision makers.

This publication supports WHO Euro’s policy framework, Health 2020, which seeks to support a wide range of actions that can improve health. A component of Health 2020 is the European Action Plan for Strengthening Public Health Capacities and Services, which is structured around the 10 essential public health operations (EPHOs). The ‘Case for investing in public health’ specifically supports the strengthening and delivery of EPHO 8: Assuring sustainable organizational structures and financing.

Many governments have responded to the global economic crisis by reducing budgets. As the second largest area of public expenditure for most countries, health is in the financial spotlight. At the same time, there is upward pressure from the rising costs of technologies and pharmaceuticals and, to a lesser extent, from demographic changes, most notably our ageing populations. Austerity policies themselves provide an additional upward pressure from ill health associated with rising unemployment and, for those still in employment, increased job insecurity combined with wages that fail to keep pace with inflation.

This publication describes the economic and health benefits for individuals and governments of a public health approach by setting out the costs of failing to address current public health challenges. It then provides evidence of the cost–effectiveness of public health and prevention approaches across all levels of prevention including the wider determinants of health, resilience, health behaviours, risk factors, vaccination and screening. It includes the recommendations from WHO’s study of the costs of scaling up action to prevent and reduce the impact of non-communicable diseases (NCDs) and identifies those preventive interventions that show evidence for early returns on investment, not just longer-term gains.

The current costs of ill health are significant for governments in Europe: trends indicate we are headed down an unsustainable path of ever increased cost unless cost-effective policies are put in place.
•    Ageing populations with higher rates of NCDs have increased demand, while health care costs have generally increased.
•    The costs of health inequalities – the total welfare loss across 25 European countries – are estimated at 9.4% of gross domestic product or €980 billion.
•    Cardiovascular disease and cancer cost the countries of the European Union €169 billion and €124 billion respectively each year.
•    Tobacco use reduces overall national incomes by up to 3.6%.
•    Air pollution from road traffic costs the countries of the EU €25 billion, while road traffic injuries cost €153 billion each year.
•    Obesity accounts for 1–3% of total health expenditure in most countries; physical inactivity costs up to €300 per European inhabitant per year.
•    Mental illness costs the economy £110 billion per year in the United Kingdom

Some of these health costs could be avoided by shifting investment to prevent harm and increase activity in health improvement, disease prevention and health protection. Funding for public health and prevention remains a small proportion of overall health spending, despite potentially representing excellent value for money, with gains in the short and the long term, and savings for both healthcare and wider sectors of society. European governments currently spend an average of only 2.8% of their health sector budgets on prevention .

The economic justification is clear. The trend for steadily rising health and social care costs, as well as the costs of inaction, show an unsustainable situation. There is good evidence to support an expanded role for health improvement and disease prevention to increase value for money and, for some approaches, to go further and actually create a return on investments for health and other sectors, as well as potentially promoting an increase in wider economic productivity.

Many of these cost-effective interventions can also help to reduce inequalities. For example, those addressing mental health and violence prevention, which are issues disproportionately affecting population groups already suffering from adverse effects of health inequality. Investing in upstream population-based prevention is more effective at reducing health inequalities than funding more downstream approaches .

The publication provides examples of economic evidence for interventions in different areas relating to health. This illustrates the cost of inaction or “business as usual” and then outlines the cost–effectiveness of interventions. The evidence shows that a wide range of preventive approaches can be cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening.

Examples of prevention interventions that can give returns on investment within 1–2 years are provided and include the areas of: mental health promotion, violence prevention, healthy employment, road traffic injury prevention, promotion of physical activity, housing insulation as well as some vaccinations.

The evidence presented demonstrates the potential benefits of cost-effective prevention, using whole-system approaches and inter-sectoral partnership working. It shows that public health can be part of the solution. This is presented in an accessible format with short quick to read text and explanatory diagrams to encourage its use beyond the traditional public health world and help provide a tool for advocates in countries where public health may not be as strong as here in the UK.

This short video presents the key messages featuring international public health experts including a former president of FPH:


1) The case for investing in public health. Copenhagen: WHO Regional Office for Europe. 2015. (accessed 3 July 2015)
2) Health 2020: the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
3) European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
4) Scaling up action against NCDs: How much will it cost? WHO report 2011 Copenhagen: WHO Regional Office for Europe (accessed 3 July 2015).
5) Global health expenditure database. Geneva: World Health Organization (accessed 3 July 2015).
6) Orton LC et al, (2011). Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health.11:821.

  • By Dr. Trevor Hancock
  • Professor and Senior Scholar
  • School of Public Health and Social Policy
  • University of Victoria
  • British Columbia, Canada

Key points

  • We need to be more assertive in stating that public health is by far the most complex, challenging, interesting and holistic specialty in the health sector.
  • Public health is really a branch of human ecology, concerned with the health implications of the interactions of our culture and society with the built and natural environments.
  • Not only are we highly urbanised, we spend the vast majority of our time indoors, so the built environment, as a setting where the physical and the social interact, is a large factor in determining our health.
  • Nonetheless, we live 100 percent of the time within natural ecosystems on a small planet, and these natural systems – which are in decline – are the ultimate determinant of our health.

First, my sincere thanks for the honour you are bestowing on me, There is no greater honour than to be recognised by one’s peers, especially in another country, and especially by such a respected body as FPH. I have worked in public health for over 35 years, and plan to keep going until they nail down the lid of my coffin. Along the way I have learned a few things I would like to share.

Public health – the most complex specialty of all

First, health is almost entirely different from health care and medicine. While I graduated in medicine (from Bart’s), I sometimes tell medical students that I later graduated from medicine to health – and in the process, I had to un-learn medicine.

While medicine – and indeed, all the healing professions – are a noble cause, I truly believe that public health is a higher calling! Surely there are few jobs more important than keeping people healthy, protecting them from harm and preventing them from become sick or injured in the first place or dying prematurely.

Moreover – and this is something we seldom say, and not loudly enough – public health is by far the most complex, intellectually challenging and exciting of all the health professions. I like to tell medical students that by comparison with public health, neurology or heart surgery or other medical specialties are comparatively simple. Because in public health we not only need to know the biological and clinical sciences and epidemiology, we need to know ecology, urban planning, sanitary engineering, architecture, anthropology, sociology, community psychology, policy, planning, administration, communications, education, politics and more.

We need to extol the virtue of the generalist, or more precisely, the holist. Like society as a whole, we have failed to recognise that generalism or holism are in fact specialties in their own right, as are those that practice these ways of thought and action. Here I include the practitioners of family medicine as well as public health practitioners.

In fact, the multiple, complex and interacting ecological and social threats to health that we face in the 21st century cannot be solved by specialists, but by holists, who can see and recognise the patterns, understand and act on and within complex adaptive eco-social systems.

Public health as human ecology

Public health is really a subset within the discipline of human ecology – which was once wonderfully defined as “the study of the issues which lie at the interacting point of environment and culture” (Dansereau, 1966). It was the incorporation of these concepts in my work – as well as the thinking of mentors such as Harding LeRiche and John Last, who both wrote books on public health and human ecology – that led me to develop the Mandala of Health: A Model of the Human Ecososytem – together with my close friend and colleague Fran Perkins in Toronto in the early 1980s in Toronto (Hancock and Perkins, 1985; Hancock, 1985).

TGraphic of a tree, with both the branches and roots made of people,he socio-ecological approach embodied in this model has been core to all my work in public health, and should be core to the practice of public health at any level. Thus while much of my work in the past 40 years or more has been focused on the natural and built environments, it is important to understand that they both are eco-social systems.

We are now past the point at which more than half of humanity is urban, and in high and even many middle-income countries, that figure is 80 or even 90 percent. Moreover, we in the high-income countries spend about 90 percent of our time indoors. So the built environment is in many ways our most important environment.

But our cities and communities are in fact settings (as are our homes, schools, workplaces, hospitals, prisons and so on), which means they are places where the physical and the social environments intersect and interact. In fact, human ecology in part grew out of an attempt to understand cities in the 1930s. So the creation of healthy cities is an eco-social challenge.

However, while we may spend almost all of our time in built environments, we still live 100 percent of our time on the Earth, and within global and regional natural ecosystems. Those ecosystems are in trouble, and the cause is human activity. It’s not just climate change, bad though that is.

It’s also depletion of resources, especially those related to food production such as agricultural land and water; mounting damage to the oceans, which further threatens food supplies; the pollution of entire ecosystems and food chains – and ourselves – with persistent organic pollutants and heavy metals and – as result of all these and other changes – the start of a sixth great extinction, this one caused by us.

We are passing planetary boundaries for ecosystem stability in several key areas. But when ecosystems decline or collapse, so too do the communities and societies embedded within and dependent upon them.

All of these ecological changes – which are so massive and so significant that geologists are have been considering declaring a new era, the Anthropocene – constitute a massive threat to the health of the population – which means they are a public health issue, on a mammoth scale.

Public health must now adopt an eco-social approach in addressing the health implications of ecological decline (just as we did in addressing the health implications of industrialisation in the 19th century) in its task of creating a more just, sustainable and healthy future.

Public Health in the Anthropocene: Addressing the ecological determinants of health

While we have paid great attention to the social determinants of health in recent years, which I agree is important work, we have largely ignored these ecological determinants of health. That is why I have spent the past three years leading a workgroup for the Canadian Public Health Association examining the ecological determinants of health and the public health implications of global ecological change (the CPHA Discussion paper) and the 100 page technical report.

In our report we make it clear that the ecological and the social intersect and interact. The massive and rapid ecological changes we are seeing are driven by major social and economic forces which are themselves driven by social and cultural values rooted in Western notions of ‘modernization’, progress, development and growth. However, these driving forces contain within them the seeds of their own destruction. Clearly, we have to address them as a single eco-social problem.

In the 19th century, we confronted the massive challenge of industrialisation and urbanisation, and together with our reformist allies in many other sectors, we faced and largely dealt with that challenge. Of course, cities are still a challenge, especially the rapidly growing cities of the low and middle-income countries, so there is still much work to be done.

For the past 40 years the environmental movement has been doing public health’s job. Now we need to step up to the plate. We need to once again become leading players and partners in a process of reform, this time to create a more just, sustainable and healthy future for all. To do so we need to address both the urban health challenges and the global ecological changes we face.

We must educate the next generation of public health professionals in the context of human ecology and systems thinking, so they can take an eco-social approach to these massive challenges. Above all, we must become activists and advocates for economic, social, cultural and political changes that take us away from our present unhealthy course and that help steer us towards the more just, sustainable and healthy future we must create for future generations.

That is my challenge to the public health profession and to FPH. I hope you take it up.


Dansereau, P. (1966) 1st Commonwealth Human Ecology Council Conference, London.
Hancock, Trevor (1985) The mandala of health: a model of the human ecosystem Family and Community Health 8(3): 1-10.
Hancock, Trevor and Perkins, Fran (1985) The mandala of health: a conceptual model and teaching tool Health Education 24(1): 8-10.

  • by Ben Barr Senior Clinical Lecturer in Applied Public Health Research, and David Taylor Robinson Senior Clinical Lecturer in Public Health Research
  • Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool

The chancellor has committed to the NHS plan, which says “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”

Yet his announcement of a £200 million cut in public health funding, contradicts that statement and puts the NHS plan at risk. This 6.2% reduction in the public health budget will have adverse consequences for the health and wellbeing of the communities served, as well as increasing future demands on the NHS. Many public health services are cost saving, meaning that this action is likely to cost the Treasury much more than £200 million in the long run (1).

But will all areas be affected equally? This will depend on where the cuts fall, with the harm caused proportional to the absolute reduction in resources in each area. The £200 million cut is the equivalent to a reduction of just under £4 per person in England. Quality Adjusted Life Year (QALYs) (1) are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality of life score. A cautious estimate of the cost effectiveness of public health interventions is £633 per QALY gained, which would indicate a potential reduction of 600 QALYs per 100,000 population or 32,000 QALYS in total. Previous austerity measures, in particular cuts to local authority funding, have not been applied equally, but have hit the poorest hardest (2). Public Health England is to consult with local authorities on how these new cuts will be implemented and it remains to be seen where the axe will fall.

Graph final

Figure 1 shows the likely impact of three possible scenarios for distributing the public health budget cuts across local authorities (LA):

1. a flat cut of 6.2% to each LA;
2. a Pace of Change (PoC) policy with the percentage cut distributed according to each LA’s distance from their target allocation in the PH allocation formula , and
3. a needs weighted cut, with the absolute cut in funds in each LA, inversely proportional to the level of need in that local authority. For example, an LA with twice the average level of need, as measured in the PH allocation formula, would receive half the average cut.

The effect of these three scenarios is shown for all local authorities, divided into five groups, from the most deprived 20% to the most affluent 20%, both in terms of the absolute cut in resources per head of population and how that translates into QALYs lost, assuming an average cost effectiveness of public health interventions of £633 per QALY.

The flat cut and PoC scenarios clearly have the potential to increase health inequalities. A flat 6.2% cut to all local authorities would have a greater adverse impact in poorer parts of the country. Somewhere like Blackpool BC would lose £9 per head of population, whilst Surrey CC would only lose £1.70 per person.

A Pace of Change model would have an even greater adverse impact on poorer areas. As more deprived local authorities are more likely to be over target, poorer areas would receive an even greater cut in funding in this scenario. Blackpool BC would lose £19 per head of population, whilst Surrey would lose only 70p per person. This would come on top of larger cuts in core local authority budgets that have already occurred in these areas, with Blackpool BC having lost £225 per head from its core budget since 2010, whilst Surrey CC’s budget has only been reduced by £53 per head (3).

There is evidence that each pound of public health investment results in larger health gains in deprived populations (4) and therefore each pound cut may have a even greater adverse impact in more disadvantaged areas. If that were the case this analysis would under-estimate the overall adverse impact of these funding scenarios on health inequalities.

The needs weighted option is unlikely to increase health inequalities. In this third scenario, since the level of cut in each LA was weighted by the level of need, the cut is lowest in the deprived local authorities that have the highest needs. In practice any policy that results in a higher absolute cut in resources from poorer areas as compared to more affluent areas is likely to increase health inequalities.

Cutting public health funding is likely to damage people’s health, increase demand on the NHS and cost more in the long run. But if these cuts fall hardest on the poorest parts of the country they are also likely to widen health inequalities. We already have some of the largest differences in health between regions, of any country in Europe. These result from and contribute to the massive economic divide between the richest and poorest parts of the country (5). Reducing rather than increasing these inequalities is not only a matter of social justice, but will also be necessary for the government to achieve its aim of rebalancing the economy.

References and further information

PoC policy assumes the minimum cut is set at 3% and the maximum cut rate is set at 15%. The local authorities that are most under target get the minimum cut of 3% and those most over target get the maximum cut of 15%. A number of local authorities who are relatively over target, but not the most over  target, receive a cut above 3% but under 15% depending on their position from target relative to all other local authorities.

Other references:

(1) Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Public Health 2012; 34: 37–45.
(2) Whitehead M, McInroy, N, Bambra C, et al. Due North Report of the Inquiry on Health Equity in the North. Liverpool: University of Liverpool and the Centre for Economic Strategies, 2014.
(3) Local Government Finance Settlement 2014-15 and 2015-16. .
(4) Barr B, Bambra C, Whitehead M. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014; 348: g3231–g3231.
(5) Bambra C, Barr B, Milne E. North and South: addressing the English health divide. J Public Health 2014; 36: 183–6.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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