Director of Research & Policy
ASH

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

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

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

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

Plain Packs

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

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

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

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

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

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

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

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

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

• Encourages and facilitates learning – particularly in science

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

• Improves awareness and understanding of the natural environment

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

• Supports school improvement and development

• Strengthens communities and interaction.

Improves achievement

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

Builds life and employability skills

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

Improves health and wellbeing

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

Founder and Director, Kids Company

I watched a young man biting his arm who believed that, as a bird, he was pulling out feathers. There was no parent to care for him; for a long time he had coped alone. Let me evidence the invisibility of children like him who, at best, survive on leftovers of other people’s care and, at worst, shut down hope to avoid disappointment.

Kids Company supports 17,000 children and young people with psychosocial care. Recently, our work with 668 disadvantaged 16- to 23-year-olds highlighted dark statistics.

Just under 560 were not registered or connected with a GP; 411 required mental health interventions; 87% had experienced multiple trauma; 394 required housing; 365 needed sexual health interventions; 436 had to be registered with a dentist; 363 required an optician’s assessment.

These are citizens of the underbelly whose needs remain invisible and unmet. Young people have little faith in civil society’s ability to reach out to them. As one put it: “The government hates us.”

Young people believe this because the narrative emanating from politicians is often unwittingly derogatory. Tuition fees have increased, the EMA grant has been stopped, housing benefits have been cut. No-one will rent a room to a young man for fear that he may trash their house, and yet he cannot live in his own flat or bedsit, because £70 a week is the maximum allowance for his rent.

During the [2011] summer riots the TV cameras didn’t follow all those children who stole food. Instead they focused on those who took plasma TVs and trainers.  Forty-two per cent of the young people brought before the courts were in receipt of free school meals. But we are too frightened to see need. Instead, we see greed.

So what brought these desperate young people to such extremes of rage? Don’t go looking for big answers. The truth resides somewhere smaller: in that insidious space where human dignity is systematically eroded. The kids describe it as “stress”: the door of possibility slamming in their faces.

They’re told to have aspirations, but noone will pay their college fees. They’re told to get fit, but no-one will give them money for the gym. They’re told to eat well, but they have no more than £10 a week to buy food while on benefits. They’re told to see their doctors but don’t have enough phone credit or patience for the booking queue.

With 1.1 million children and young people having mental health difficulties in the UK, you’d be forgiven for thinking we were organising a nationwide famine in therapeutic support. Children need an integrated approach to wellbeing, taking into account their range of psychosocial needs in the context of sustained care relationships – not this lucky-dipping for healthcare.

Proximity would yield mutual solutions – healing the wounds of the banned age with a  bandage. Bandages support, hold and promote self-recovery. If a piece of cloth can do it, why can’t we?

This article first appeared in the December issue of Public Health Today, FPH’s quarterly magazine.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

At this moment in time thousands of public health nurses are left in limbo, seeing changes on the ground but with no real news or updates from the people making them. The RCN is concerned that significant changes are being made to public health staff, in the absence of the guidance promised by the Government.

In the Update and Way Forward policy statement in the middle of July, the Department of Health committed to producing updates on the five key areas of reform during the autumn. Just to be clear, this set of work is an overhaul to the way we tackle public health issues, it isn’t a list of mere tweaks and small changes.  In case you aren’t aware, the five areas are:

• Public health outcomes framework
• Public Health England operating model
• Public health in local government and the director of public health
• Public health funding including shadow local authority allocations for 2012-13
• Public health workforce strategy consultation

Here at the RCN, we understand that the shadow budget allocations and consultation on the workforce strategy may not be released until 2012. What’s more, there is no sign of updates on the remaining three areas as 2011 draws to a close; meanwhile, RCN members are being affected right now.

Back in early November, the RCN welcomed the Health Select Committee’s report on Public Health; it recommended that uncertainty around the future structure and focus of public health in England must be resolved as quickly as possible. You can understand why we’re now concerned.

At the time, the RCN Chief Executive & General Secretary, Dr Peter Carter, commented that “Many public health nurses are currently in a state of limbo as they wait to see how proposed transfers to local authorities will affect their jobs and the services they offer to the public.”

While we understand that the issues requiring consideration are significant, nursing staff need clarity and deserve answers. On behalf of public health staff everywhere, I very much hope that 2012 provides us with more information, not only for the benefit of staff, but the patients who are so dependent on the care that they provide.

The Health and Social Care Bill 2011 represents the biggest threat to public health for 60 years and it is time for the public health community to stand up and say so.

Deliberately conceived as an ‘Abdication and Abolition Bill’, the proposed legislation would sever the duty of the Secretary of State to secure and provide comprehensive healthcare throughout England.

Entitlements to health care are to be abandoned in order that a consumer market can be substituted for a needs-based system and, in David Cameron’s words, the NHS turned into a “fantastic business for Britain”.

As these briefings to the House of Lords show, the Bill will destroy the public health foundations of comprehensive healthcare and the ability to gather information and monitor inequalities.

Geographic administrative units – the hallmarks of the NHS – are to be abolished. Whilst commissioner populations will be made up from GP registrations, GP boundaries are being dissolved.  Patient enrolment and disenrollment will lead to unstable denominators and render fair service allocation and planning impossible.

No-one will have ultimate responsibility for ensuring everybody in a geographic area gets access to a GP. Above all, the ability to monitor equity of access within a comprehensive system will be undermined by lack of data and local variations in entitlement.

Public health will be shunted out to local authorities but the resources, functions and services that will go with it are not defined.  It is even impossible to tell the populations for which it will be responsible.

Local authorities and clinical commissioning groups will have enormous freedom to decide what they will and won’t provide and the boundaries between chargeable and non-chargeable services will be blurred and subject to local eligibility criteria.

In place of equity will be service and patient selection by commissioners and service providers intent on managing the financial risks of the marketplace.  Commissioners will be allowed to outsource their functions to healthcare companies that specialize in these techniques.

The marketisation of healthcare will lead to the denial of care on a scale not seen in England since pre-war days.

At a minimum the Bill must be amended so as to restore all the Secretary of State’s duties and functions and the structures of a national public health service.

The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Credit: Andrew Hood, using wordle.net

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now.  The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
•    An independent and robust Public Health England;
•    A coherent career and training structure for public health professionals;
•    Protection of terms and conditions of staff;
•    Directors of public health reporting to chief executives of councils,
•    Clarity in the size and applications of the ring fenced budget and
•    Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage.  However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began.   NHS planning has historically relied on regulations and guidance, not legislation.  This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog.  It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.