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Sometimes I think politicians must be smarter than they seem when baying during Prime Minister’s Questions.  I’ve spent the past couple years or so discussing pension reform with relevant actors within the social policy process (academics; civil servants; employers; politicians; professions; think tanks; trade unions) without realising that UK Members of Parliament had built an escape clause into the legislation.  As Therese Coffey (Secretary of State for Work & Pensions) explained to the House of Commons last 4th December: Section 27 of the 2014 Pension Act demands a second Government Review of the State Pension Age by May 2023, for which already she has commissioned independent reports from Martin Clarke (Government Actuary) and Lucy Neville-Rolfe (Peer of the Realm) – all three of whom, it may be relevant to note, will be entitled to solid gold pensions when they retire (non-contributory, defined benefit, final salary). 

If you look at the ONS Longitudinal Study, it is clear that at each decennial census since 1971 the proportion of women in their 50s who describe themselves in labour market terms (paid employment; unemployed; permanently sick; retired) has increased steadily, so it is reasonable that women and men should have the same State Pension Age, although why the gender difference should have been equalised up (first to age 65 years, now 66 years and soon 67 years, then 68 years) rather than down (to age 60 years), is less obvious.          

The official reason is the increase in life expectancy during recent decades.  One problem with this explanation is that the rate of increase in life expectancy now appears to have stalled and that, if and when it resumes, it is likely to lack its previous vigour.  The bigger problem is that being alive is not the same thing as being capable of holding down a job; hence the need to think in terms of healthy life expectancy.  Here the devil is in the detail and Lucy Neville-Rolfe has been tasked with adjudicating.  John Cridland’s previous review opted to measure the healthy part of healthy life expectancy in terms of self-assessed health, although many consider that the absence of physical or mental disability would have been more appropriate.    

I am one among the number who would prefer to see the State Pension Age linked to disability-free life expectancy, but my concerns are not limited to this technical issue.  I am also part of an informal group of public health specialists who wish to draw attention to the possible unintended consequences of raising the State Pension Age and contribute to discussion of how to mitigate these.        

Our concerns are that extending work-life may: (1) worsen the health of those with pre-existing illnesses; (2) overwhelm sparse occupational health and over-stretched general practitioner services; (3) hinder informal caring at a time when the need for it is projected to increase; (4) deter the volunteering which supports the NHS and the many charities upon which public health depends; (5) trigger overt disease in those with asymptomatic pathology or previous good health.  Our report, detailing each of these items, can be downloaded free here.       

We suggest that our concerns could be mitigated by [1] commissioning two pieces of research to establish (a) evidence-based triage criteria to guide occupational health & general practitioner services in deciding which older employees are most at risk; (b) whether extending working lives will increase the mortality risk of older employees in the most disadvantaged occupations. And [2] two changes to administrative regulations to accept (a) greater flexibility in the age range 60-68 years, to accommodate patterns of relapse and remission in chronic disease; (b) that paid employment is not the only type of socially necessary labour at these ages, with informal caring and volunteering as appropriate and legitimate alternatives.

Finally, there are issues of financial loss and workfare.  Many of those now working until age 66 years spent most of their life paying their National Insurance contributions when its regulations increased the size of their State Old Age Pension in line with any years worked beyond the state pension age; the increase in the state pension age removed this entitlement, at a cost per person of up to £300 per month for life which, for Pension Credit recipients, could be the difference between living with or without the older person’s Minimum Income for Healthy Living.  To add insult to injury, now these same individuals find themselves subject to conditionality (fitness for work testing) and sanctioning (benefit cuts), which those who saw the Dispatches report on the subject (Channel 4, 17th December 2021) will find it hard to believe that MPs intended when they voted through the 2014 Act.    

David Blane
Professor Emeritus of Imperial College London

The Yorkshire and Humber speciality registrar committee spent time reflecting on 2021, with a focus on the challenges we have faced and the positive things which have supported wellbeing. The COVID-19 pandemic has seen working from home become the norm for many public health professionals, and this was prominent in our conversations.

Office for National Statistics (ONS) show that the proportion of working adults who did any work from home increased in 2020, and 85% of those currently homeworking wanted to use a “hybrid” approach of both home and office working in future1. If working from home is to become a norm of working life, we must work together to support wellbeing.

Challenges

The pandemic has had a profound effect on everybody. There are some aspects which we cannot control and must live with. This can leave us feeling quite bleak and such feelings are particularly prominent at times when restrictions change.

Many registrars have undertaken placements without meeting their colleagues in person. A lack of human interaction face to face left people feeling disconnected. There is more challenge in building relationships with colleagues and partners.

The line between work and life can become blurred. People might be working at their dining table or in their bedroom. As well as this physical blurring of work and home, there is a psychological blurring too. There are back to back meetings which might not leave much time for admin and replying to emails. It is “easier” to start early or stay late.  It is “easy” to pop back to your work area.

Culture and leadership really set the tone for wellbeing. In Yorkshire and Humber, registrars receive regular wellbeing check in calls from the Head of School and Training Programme Directors. I extend thanks on behalf of the registrar body to the School of Public Health Team for their support and for setting the tone for a positive culture. These tips are based on experiences in our region which have been helpful. 

Top tips to support wellbeing for organisations and leaders

  1. Create mini breaks by starting meetings at five past the hour
  2. Encourage protected time for lunch, including getting outside during day light hours in winter
  3. Encourage meeting free time each week (e.g. 1 meeting free day per week)
  4. Thanking people for good work they have done
  5. Flexibility in working hours
  6. Hold regular meetings that help teams to keep in touch (e.g. weekly registrar catch ups)
  7. Offer walking meetings using telephone rather than video conferencing where able
  8. Consider optional weekly wellness sessions (e.g. desk-based stretches, mindfulness)
  9. Care about people – share good news, respect their personal circumstances, support time off if people are unwell
  10. Lead by example – be open about vulnerability, take annual leave, block out lunch breaks, have meeting free days

Top tips to support wellbeing for individuals

  1. Being kind to yourself
  2. Shut the computer at breaks and the end of the day
  3. Set your out of office on none working days
  4. Taking you work emails off your phone
  5. Organise your time to include breaks and meeting free time
  6. Go out during the daylight
  7. Take time to exercise
  8. Remind yourself of things to look forward to, no matter how small!
  9. Work on your support network e.g. action learning set, peer coaching

Dr. Jaimee Wylam
Public Health Registrar

  1. Business and individual attitudes towards the future of homeworking, UK – Office for National Statistics (ons.gov.uk)

Mosquitoes winging their way north across Europe bringing dengue. Floods and drownings. Heat stress. Despair. We are all aware of the health impacts of climate change. But how do we get governments to act? Ballot box pressure (in democracies) does not guarantee results as shorter-term concerns distract from our overheating planet. No easy answers, but experience from the environmental movement provides clues and inspiration.

On 7 October the Faculty of Public Health co-hosted a webinar on Public Health, Climate Change and Strategic Litigation (recording now available online). It aimed to alert public health academics and practitioners to the opportunities for legal action to hold governments and private sector polluters to account for health-harming pollution and climate change.

Moderated by Dr Farhang Tahzib, the webinar attracted over 800 registrations from around the globe. Starting close to home, Rosamund Adoo-Kissi-Debrah recounted how air pollution in London led to the death of her daughter, Ella. Sir Stephen Holgate gave expert testimony at the coronial enquiry into Ella’s death. He noted how air pollution is now largely invisible and hence neglected – yet ‘breathing clean air is a right, just as we have the right to clean water.’ Dr Maria Neira, WHO’s climate change and health champion, presented the ‘health argument for climate action’ that WHO will take to CoP26.

But governments have long been aware of the short- and long-term health impacts of pollution. What else can be done? Strategic alliances between public health actors, environmental activists and legal academics and practitioners are using court action to highlight government inaction and industry abuses. Marlies Hesselman, lecturer at the University of Groningen, Netherlands, gave a ten-minute ‘strategic litigation 101’, noting four recent and current cases where governments have been called to answer before international courts and tribunals for health harms related to climate change. Irmina Kotiuk, senior lawyer with ClientEarth’s Clean Air Program, noted the huge role for public health specialists as experts in strategic litigation – building on the experience of tobacco and asbestos. She urged nurses and doctors to collect and record evidence in medical files which can later be used in expert testimony.

Richard Harvey, barrister and legal counsel for Greenpeace, drew parallels between tobacco companies’ now infamous denials of the link between smoking and ill-health, and today’s spin from fossil fuel companies. The Dutch District Court in The Hague was not fooled – in a landmark 2021 decision it ordered Shell to reduce CO2 emissions by 45% by 2030, globally. Dr Marina Romanello, Research Director for Lancet Countdown, reiterated the health impacts of climate change and the continuing financing of the destruction of our health through fossil fuel industry subsidies.

Yet the Lancet Countdown 2021 report on health and climate change: code red for a healthy future, makes no reference to the role of the law (other than to the International Health Regulations), let alone to the hundreds of current and recent legal cases on climate change alone, easily searchable through online databases. Restating the problem in ever greater detail is not a strategy for change. We need to combine the credibility of hard science with the legal skills of seasoned national and international litigators and the experience in social mobilization tested and proven by other social movements – all adapted to today’s online, COVID-19 constrained world. Dr Neira remarked that ‘People working in the environment say we need to hear more from the public health community – because you are still trusted – politicians will listen to you.’

Bridges between the public health, environmental and legal communities must be strengthened if we are to ‘keep 1.5 alive.’ The 7 October webinar was co-hosted by the Global Health Law Groningen Research Centre and the ‘law and public health’, ‘environment and health’ and ‘ethics and public health’ sections of the European Public Health Association. Section membership is free and not limited to public health practitioners or people resident in Europe.

David Patterson LLM. MSc.
PhD. Candidate
Global Health Law Groningen Research Centre
Netherlands

Today (Sunday) is a day of rest at COP 26.  That is, in the formal Presidential Programme, but there are still plenty of ‘side’ events happening.

I have had a few interesting days at COP 26 so far. It is VERY busy with many parallel sessions and activities going on, both inside the main blue zone and in the green zone and at satellite meetings. It is quite hard (maybe impossible!) to follow the president’s programme and the negotiations as the ‘agenda’ for each day only appears late the night before, so it is difficult to plan. Also many of the ‘negotiation sessions’ are not really negotiations, but are a series of announcements about various initiatives and commitments that countries (and / or organisations) have signed up to, but the real question is whether they will deliver on them, as there is often only a headline and no tangible substance about delivery given.

There has been a calculation made that if ALL the pledges made so far are enacted then the figure reached would be 1.9 degrees Celsius, which is better than the calculated 2.7 for which we were previously on track  BUT still does not reach 1.5 degrees, AND there are certainly doubts that all the promised actions will be fulfilled. Previous promises have not been fulfilled.

At the Paris COP there was agreement that $100bn would be transferred, by 2020, from global north to those countries who needed to address climate change most (i.e. LMICs in global south) but that promise has not been fulfilled, although there is now a commitment to do so by 2023. (We shall see!) 

I was going to outline some highlights for me from the past few days, but I was just distracted listening (on you tube) to the first session of the People’s Health Hearing. It was amazing. Stories and testimonies from people who have suffered directly the impact of climate change. A testimony from the Philippines about the massive floods a year ago (November 2020), stories of having to sit on their roof until the water went down, of raw sewage and water pouring into their houses and trying to clear it up, of rashes and scars from contact dermatitis, of the mental health impacts of having to move house 4 times in the last year and most particularly of the inequalities (as we in Public Health would call it)  – of the peoples who have contributed least to global emissions being the most affected. Calling for ‘climate Justice’.

 And another story of how it was the removal of massive areas of trees, by extraction industry (mining etc. for natural resources including gold and fossil fuel), that caused the area to flood, and how the indigenous people, losing their homes and communities, livelihoods and lives, are now being gagged by their (and global north) governments who are still supporting the industries.

And yet another concerning mining, in an indigenous region – West Papua (west part of Papua New Guinea) about the devastation and pollution ruining their water supply and crops and an anthropologist from the community who was murdered, (together with 130 others from the community) – and how the family had to flee to the Netherlands – and that the anthropologist was the storyteller’s father. No wonder he is now an indigenous activist. But how does this link to Climate change, well through the need to protect forests and the staggering statistic that indigenous people populate 5% of the world’s land but their forests are responsible for nearly 90% of biodiversity. They have maintained that for 1000’s of years, living in harmony with nature, unlike western societies. We must learn from them and protect indigenous people and their lands, if we want to avert the climate crisis.

Very powerful stories, I do not do them justice here. And what I learn from this is that we must use stories and storytelling and we, as PH professionals, should learn more about storytelling, find the people who are directly affected and listen and learn from their experiences and utilise their experiences to influence policy makers and the climate and health agenda

Professor Sue Atkinson CBE
Chair, FPH Climate and Health Committee

So here I am on the train to Glasgow, on my way to COP 26, which started earlier this week and ends on 12th November 2021.

I am excited to be one of the FPH group with ‘observer’ status, so able to attend the main conference where negotiations take place, though I suspect many actually take place in whatever is the 2021 equivalent of ‘smoke filled rooms’! Or in fact have already taken place prior to coming to Glasgow.

 By the way COP stands for Conference of the Parties of the UKFCCC, which is the international mechanism to address climate change across 197 countries.

The first two days of COP is when the world leaders attend and many of them have made declarations as to what action their countries will take to address climate change and cut emissions, in order to reach no more than 1.5 degrees, as agreed at the Paris COP in 2015. Unfortunately the plans (NDCs) currently in place will still not go far enough or fast enough, so hence the urgently at this COP to get countries to sign up to increased targets and faster action. The science has shown that action is NOW really urgent.

The following days of the Presidents Programme are devoted to specific topics, so yesterday was on finance and today is on energy. You will have seen in the news various reports from yesterday with announcements about the financial sector agreeing to take action on fossil fuel investment, though clarity is needed on exactly what it means in practice. There were also announcements about engagement of the private sector to help finance climate action I think to the tune of $ trillions,

For the first time there is a ‘health pavilion’ at this COP and very many of the international health community are attending (including ourselves from FPH) to make the case for health being part of the agenda and that there are already major impacts on health, both direct and indirect, due to climate change. But also to demonstrate that health can be part of the solution; both health systems – the greener NHS is a strong example – and we anticipate a number of other countries may announce similar initiatives during COP. But also climate action can also improve health- for example active travel, with increased cycling and walking, reduces emissions, reduces air pollution (improving health) and improves physical activity, which improves people’s health.

Similarly more plant based, sustainable food is better for people and better for the planet.

But we are also here to remind everyone that there is a climate justice / health equity issue, both across the UK and globally. The most vulnerable are likely to be hit hardest by climate change – poor housing is least resilient to higher temperatures or flooding and internationally global south has contributed least to the current emissions but are already feeling the impact of climate change with increased extreme weather and its sever impacts.

So what do I expect to do at COP?

  • Hopefully contribute to that health voice, both informally and collectively in speaking to country delegates. Or really just anyone who might listen
  • Certainly listen and learn both from other countries and from other sectors such as energy and transport. We, in public health, need to hear where they are coming from and what language they use and see how our agenda on health and inequalities etc. can fit in and contribute to what they want to achieve. That way we can work together for a win win.
  • Feel the buzz of collaborating with the international health community working together to address climate change and all its health ramifications

That will do for now.  

Sue Atkinson

4.11.21 at COP 26 in Glasgow

In public health we often work in partnership with statutory and non-statutory organisations developing relationships that are necessary to implement public health projects to benefit local communities.  How often have we teamed up with colleagues where the relationship is informal, not prescribed and not expected?

April 2020 the national spotlight was on acute physical health care and there was a frantic attempt to scale up provision of acute beds and ventilators. Those of us working in community Trusts saw our services take a back seat and many were stopped altogether; but there was unease over impending problems over the horizon. What would be the impact on community rehabilitation services? What would the mental health ramifications of the pandemic be?  Would our community palliative care services cope?  

It was reassuring to network with other public health colleagues who had similar concerns. Connected by the national network for public health professionals working in providers (facilitated by PHE) we joined forces and worked as one team on this topic of mutual concern. One of the challenges for public health specialists in provider trusts is that we often work single-handedly and don’t have colleagues in a team, as in local authorities for example. Becoming a virtual team (consultants, StRs) doubled the number of people working on the project and meant we could split up article reading and writing up. It also gave us more brains to think about the implications and critique what we were reading and thinking. We barely knew each other, but had our training in common and shared public health language meant that we were able to work effectively together – and enjoyably!

So even before the term Long Covid had been coined and mental health concerns had been profiled nationally, we had teamed up and started needs assessments and were doing papers for our local integrated care systems. We even managed to submit articles for publication. 

Furthermore, we have continued regular problem solving meetings and act as a virtual department separated by a dotted line of a few hundred miles. Freed up from formal, standard ways of working – under the radar – our organisations get a greater range of public health expertise than they pay for!

Jane Beenstock
Consultant in Public Health

Dr Zafar Iqbal
Associate Medical Director Public Health
Chair, FPH Pakistan SIG

Given the widespread recognition of COVID-19 as a public mental health emergency that has deepened existing mental health inequalities, the theme set by the World Federation for Mental Health for World Mental Health Day on Sunday 10th October – Mental Health in an Unequal World – was especially fitting.

It seemed to have come around even more quickly again this time, which probably says a lot about what the past year has been like. Those of us working in public health will be well versed in efforts to promote wellbeing in our own organisations and others, particularly at a time when workload and stress have been high and morale has been low.

What comes through less clearly is where the focus is not just on reducing stress in individuals, but on tackling wider underlying issues contributing to that stress – particularly where there are marked disparities.

I don’t just mean equal access to support, services and activities that help to improve wellbeing, although that is extremely important – both in our own workforces and the populations we serve. I’m talking about workplace policies, working practices and cultures that seek to actively counteract prejudice, discrimination and structural disadvantage, all of which are detrimental to mental health and wellbeing.

In other words: what are we doing to advance equality in our own workforce?

Last year the FPH highlighted the importance of embedding anti-racism into public health practice. This means challenging our own unconscious biases and refusing to be silent bystanders to racism in our own organisations. The same principles can be applied for other forms of discrimination, including but not limited to sexism, ableism and homophobia – however, this is as much about questioning the status quo in the ways we work as it is about challenging overtly discriminatory behaviour.

The public health workforce is diverse in itself (people, roles, organisations) and has wide-reaching links across partner organisations and communities. If we want to be effective advocates for mental health equality in the population, we need to start with equality overall and we need to start from within.

What stress means and what it looks like is different for everyone, but can be summarised as ‘a lack of fit between individuals and their world’ (Cassidy, 2001).[1] We’ve started to recognise the limitations of traditional workplace wellbeing approaches, which focus on supporting individuals to fit into existing structures rather than improving their ‘world’ to fit them – but we also need to be looking at who built that world in the first place. Many workplace policies and interventions for inclusion and wellbeing still operate within norms and cultures that have been established by white, middle class men without disabilities – even where workforces are considerably more diverse, and even where there is representation at senior levels.

For example, offering flexible working arrangements such as flexible start/finish times and remote working can improve work-life balance and wellbeing for people with children or care responsibilities (who are disproportionately women), or those with disabilities or long-term health conditions. Yet limiting the offer to these groups where there is no real business need to do so just reinforces the current culture as the norm and those who don’t fit in as ‘others’, instead of including everyone as equal partners in re-shaping that culture.

It also ignores the wellbeing benefits that these changes can have for everyone. A workplace that promotes equality and diversity is a workplace where everyone can flourish and feel that their contribution is valued. More flexible working as standard can help to improve work-life balance for all. Making workplaces more autism friendly can make those workplaces happier, calmer and more productive spaces for everyone. When we default to the status quo and consult rather than co-produce, we all miss out.

The brilliant Dr Nisreen Alwan explains this far better than I ever could in the context of language and anti-racism:

“Diversity” and “inclusion” imply charity from a position of power and superiority.

They give the impression that the group who is opening the door to diversify and include others still holds the key. The point of antiracism is that there should not be a key in the first place. The door should be widely open to all. Clubs with locked doors should not exist in an equitable society. Once that is achieved, the natural result of equity is diversity. It is the end not the means.”

So what does this mean for promoting mental health equality?

We cannot improve mental health and wellbeing in the public health workforce without actively tackling inequities in our workplaces – and we cannot address those inequities without confronting the structures underpinning them. Whether it’s improving opportunities and experiences of people with mental health problems, or reducing disparities in mental health and wellbeing, we have to actively change working practices that allow systemic discrimination to persist.

It isn’t enough to work to improve mental health in an unequal world; we also have to work to make the world more equitable to improve mental health.

Lina Martino

Chair, FPH Public Mental Health SIG


[1] Cassidy T (2001). Stress, Cognition and Health. Psychology Press: Hove & NY.

A public health approach in policing allows opportunities to address the clear yet complex links between health, wellbeing, offending and behaviours which lead to contact with police. Social determinants of health, such as housing, education, employment and income, often mirror or overlap with social determinants of crime. Inequalities which result in poorer health and reduced life expectancy also result in increased likelihood of entering the criminal justice system or being policed for problem behaviours. Those at risk of offending are more likely to suffer from multiple and complex health issues, including mental and physical health problems, learning difficulties, and substance misuse.

In 2018 the national Policing, Health and Social Care consensus statement was published to set out how the police service and health and social care services would work together to improve people’s health and wellbeing, reduce crime and protect the most vulnerable people in England and Wales. In the run up to the publication of this document and in the years following public health and policing organisations have been working together, alongside other partners, to focus on prevention and early intervention, recognising that the majority of police work is rooted in complex social need. The Public Health and Policing Consensus Task Force was established to bring together these partner organisations.

The Landscape Review 2021 was published on 22 September which outlines the progress in leadership, practice, culture and evidence within policing since the publication of the consensus statement in 2018. This review describes progress and opportunities for development in four key areas:

  • policy and systems
  • evidence for primary prevention
  • public health practice
  • research in public health and policing

Policy and Systems

Since the formation of the Public Health and Policing Consensus Task Force there have been several policy documents related to public health approaches within policing. In 2019 a discussion paper was published considering what a public health approach in policing looked like. This described five key pillars for public health in policing: working at a population level, using data and evidence, considering the causes of the causes, prioritising prevention and partnership working. This paper has stimulated discussion within the policing community, ultimately resulting in the College of Policing and National Police Chiefs Council outlining the 5 key pillars as shared principles in a policy document. This and other documents explored in the Landscape Review have fostered partnerships across England and there are opportunities to build on this moving forward.

Evidence for primary prevention

It will always be difficult to prove you prevented something from happening which makes gathering evidence for primary prevention challenging. Primary prevention may also lie outside of traditional remits of an organisation (e.g. response to crime). However, for primary prevention to truly be effective all sectors must make it a priority. A mapping exercise was carried out as part of the Landscape Review which considered the evidence on the effectiveness of primary prevention in a public health and policing context. This found a lack of specific detail on “how” and “why” interventions impacted on outcomes.

Public health practice

A survey carried out by the College of Policing for the Landscape Review explored what progress has been made in embedding public health approaches in policing.  While there is evidence of effective partnership working and public health approaches more generally across a breadth of business areas within policing there is still more to do.

Research in public health and policing

Developments in policy, evidence and practice are promising, however, these must be realised in line with the evidence base. Therefore, a modified Delphi study was carried out across the four nations of the UK to identify priority topics for research as part of the Landscape Review. The results revealed a desire to prioritise wider social determinants of health and wellbeing, mental health and wellbeing, children and young people, vulnerable groups, and domestic and sexual violence and abuse in future policing and public health research.

The Public Health and Policing Consensus Task Force continue to forge and foster strong links between Public Health, Policing, Health and Voluntary Sector organisations with the ultimate aim of improving health and wellbeing of vulnerable people. If you would like to hear more about this area of work or to get involved with the work of the Public Health and Policing Consensus Task Force you can:

Dr Jaimee Wylam
Public Health Registrar

In April 2010, one of us wrote a short retrospective of the  H1N1/09 (“Swine Flu”) Pandemic, for  the newly relaunched “Public Health Today”, under the guest editorship of another of us,  entitled, “Modellers not public health doctors had lead in flu planning”.  Its sentiments were echoed in the report on the Swine Flu Pandemic for the UK Cabinet Office by Dame Deirdre Hine, former CMO Wales, that judged that the UK government placed too much reliance on “modelling evidence”.  That Cabinet Office Report went on to recommend that, “The Government Office for Science, working with lead government departments, should enable key ministers and senior officials to understand the strengths and limitations of likely available scientific advice as part of their general induction. This training should then be reinforced at the outbreak of any emergency”.  In doing so the report acknowledges that the mathematical and academic nature of mathematical modelling can be attractive to hard pressed politicians and officials who aspire to “follow the science” but warns against regarding mathematical modellers as, “court astrologers”. Public Health Today, a few short years later, was no more and with it, was forgotten, in the management of the COVID-19 pandemic, this particular lesson.

Indeed “court astrologers” have been ubiquitous in the COVID 19 pandemic from the moment in March 2020 when Imperial College London’s implausible predictions, the most recent example of a long history of the same, led directly to almost simultaneous lockdowns in the UK, France and the USA.

Meanwhile on 24th March 2020, in a letter to the Western Mail, “the national newspaper of Wales”, entitled, “Will social distancing actually work”, one of us wrote,

“This new virus will keep circulating until either we’ve all had it or vaccines or effective treatments become available, both solutions possibly years away. Distancing just makes the virus get round slower, and the pandemic last longer. Distancing also means less wealth and resilience to fight it.”

Previously, on 28th February, another of us had written in a BMJ editorial,

“Given the lessons from 2009—which taught us that containment for a globally disseminated disease was futile….once the disease is recognised as a global pandemic nations, commerce, and healthcare can move into a much more rational phase with resources targeted at those most at need. We should plan on the assumption that most of the population may contract the virus….”

Why have risk based approaches, or “focussed protection” as some have styled them, not been followed; neither in Wales nor elsewhere?  A part of the explanation has been the dominance of mathematical modelling in the scientific advisory machinery.  Welsh ministers, like many politicians and journalists, internalised the widely popularised idea of the effective reproductive rate (Rt)  as a sort of epidemic volume control responding in small increments/declines to their “cautious” changes, a framework that entirely ignores the determinant role of social networks in epidemic patterns. Welsh Government’s Technical Advisory Committee (TAC) is chaired by the Chief Scientific Advisor, not the Chief Medical Officer and despite a number of members, experienced in all aspects of infection, it has been suggested, privately, that it is the mathematical modellers that have dominated the agenda. Certainly the TAC’s outputs, available online, are consistent with this explanation, for example, a paper showing that the Welsh Government’s two week October firebreak was “successful”. In this paper, arcane mathematics is used to claim success, whilst, from a simple eyeballing of the observed COVID incidence, it would be difficult to conclude other than that any effect was marginal at best.

Whilst such global approaches to pandemic management were used, loss of a focus on risk meant that preventable infections remained unprevented, evidenced by the high proportions of deaths in which the infection was acquired in hospital or care settings and the proportion of care home cases, linked to hospital discharges.  Field data to orientate such approaches was available, early on in the pandemic from the “OpenSAFELY”, “ISARIC” and RCGP Research and Surveillance Centre projects, not to mention timely papers from China.  Public Health Wales, subsequently, made important contributions to this work with their studies of hospital discharges and of the community screening project in Merthyr Tydfil. Empirical data from field investigations might similarly be used to establish what works in protecting the vulnerable as well as to evaluate whether some of the Welsh Government’s more singular decisions (closing selected supermarket aisles, pubs prohibited from selling alcohol, vaccine passports for night clubs) were/are of any benefit.

Finally, the Wellbeing of Future Generations Act, some of Wales most forward thinking legislation singularly failed to translate into any sort of systematic evaluation of the downsides of global “lockdown” approaches; downsides most likely to impact on just those future generations whose interests the Act seeks to protect.

What scope was there for an independent stance in Wales, given the high level of economic and social interaction with England?  It has been done. Wales refused to endorse claims from DH in England that BSE could not transmit to humans, chose to wait before embarking on smallpox vaccination of health care workers, due to the high levels of side effects documented in the US, before the Iraq war and during the 2009 Swine Flu pandemic, Wales chose to use usual healthcare providers, bypassed in England by the costly, centralised and often ineffective “Flu Line” (National Pandemic Flu Service).  The scope for leadership is, nevertheless, limited but should that mean that letters to Welsh ministers, from us, suggesting how more focussed approches might look, in practice, simply remained unanswered?

So this is distinctly not the view from Wales but it is a view and a view from four of us who spent much of our senior careers in the epidemiology and control of communicable diseases.  So whatever form Wales’ Public Inquiry takes, we’d like to see our views, particularly in regard to the need to use real world surveillance and investigation, including of the downsides of interventions, taken into account and this time, practical lessons learned and remembered.

Roland Salmon
formerly, Director, Communicable Disease Surveillance Centre, Public Health Wales

Meirion Evans
formerly, Consultant Epidemiologist, Public Health Wales

Stephen Palmer
Emeritus Professor of Public Health, Cardiff University

John Watkins
Professor and Consultant Epidemiologist, Cardiff University

The COVID-19 vaccine programme has been the largest vaccine campaign in NHS history. The approach in London has and continues to be a true partnership endeavour, bringing together and harnessing the assets of all system partners and our communities in order to achieve high and equitable vaccine uptake across the city. Delivery has been multifaceted, bringing together activities at the hyperlocal, borough, Integrated Care Systems (ICS) and regional levels.

The regional Public Health function has worked to support, enable and contribute to system delivery of the vaccine programme in London by adopting a four-pillar approach focusing on:

  • data and evidence
  • tackling hesitancy and increasing confidence
  • addressing practical barriers to vaccination
  • evaluation, monitoring and system leadership

The data and evidence

Timely, high quality data and intelligence on vaccine uptake has been fundamental to London’s effort. Working closely with key London partners, we have developed a range of analysis and reports examining uptake by various groups and demographic factors. This has helped us to track progress in London and guide ongoing system efforts to increase uptake and tackle inequalities. Using presentations and analysis in creative ways has helped to demonstrate progress with delivery and highlight gaps and inequalities creating a shared understanding across partners.

Tackling hesitancy and increasing confidence

Lower self-reported vaccine confidence or likelihood of accepting the vaccine amongst London’s Black, Asian and minority ethnic communities has been mirrored by COVID-19 vaccine programme data showing lower uptake in many minority ethnic communities, and in areas of greater deprivation. Given the stark and persistent inequalities experienced by these communities in terms of risk of COVID infection and poorer outcomes, equitable vaccine uptake across the city has been a critical priority of the programme.

Engaging and working with Londoners has been central to understanding the questions, concerns and barriers experienced by London’s diverse communities. At a regional level, this has included a series of round tables with community groups including a pan-London Community Champion Coordinator programme and resources developed to reach specific communities and populations. A regional ‘bureau of speakers’ was developed to include medical and Public Health experts from a range of communities and backgrounds to support local events. From this grew the Public Health Ambassadors programme where colleagues from across PHE London used their lived experience and networks within their communities to co-design resources  and activities.

Many communities have concerns and fears that reach well beyond vaccine safety and efficacy. Historic and recent medical malpractice was a big feature as well as long standing issues of mistrust, discrimination and fear of state-run services and systemic racism. Listening to and acknowledging these fears and concerns linked to deep-seated and structural issues has been a vital first step towards rebuilding relationships and trust.

Addressing the barriers to vaccine uptake

Vaccine hesitancy is not the only factor behind inequalities in vaccine uptake, practical access issues are also key, The NHS, working with London borough colleagues and wider partners, have sought to adapt programme delivery over time in order to overcome these barriers and maximise convenience.

The use of local community venues, vaccination buses and other hyperlocal locations in non-traditional and more familiar settings are examples of this approach. Outreach models were developedto take vaccination to people who may otherwise not access them through other sites if they were housebound, homeless or asylum seekers for example. Hyperlocal vaccination options, alongside targeted outreach, such as door knocking or street engagement teams, has been effective at reaching people with barriers to access. Local booking systems were developed to overcome some of the challenges associated with the national booking system, and many sites offered walk-in clinics. Local call centres were also established to proactively follow up unvaccinated Londoners and provide support with booking.

Evaluating what we did

A pan-London evaluation of the COVID-19 vaccine programme was undertaken to learn lessons and share innovative practice in real time to inform programme delivery.

The evaluation report was recently published and is itself an example of strong collaboration and partnership across many partners. The report is divided into four distinct areas of focus – barriers, demand, access and legacy–and makes a number of recommendations in order to build on the learnings gathered throughout the programme and to drive continued improvement,  not only for the COVID-19 vaccine programme, for wider vaccines and for broader health systems more generally.

What we learnt

A vital thread across the system has been the importance of partnership working. Whilst the NHS led on the vaccine programme the strength of different partners was brought together through various elements whether it was the deep understanding of localities from Directors of Public Health and local authority partners to best practice engagement from the mayoral team. Much of this was facilitated by meeting to highlight issues and share good practice but also embedded through the agile learning of evaluating our work regularly. This enabled system partners to all constantly learn and grow together towards increasingly innovative methods and approaches.  

Another essential element has been the importance of working alongside communities to understand their aspirations, needs and concerns. This takes time, energy and resource but is vital to understand and address inequalities and is crucial to build confidence in vaccines and health systems. As we start to reflect on the last 18 months, it is essential that we take this as a legacy of learning from this pandemic – aiming to embed and sustain this approach going forwards. This is key not just for a focus on COVID-19 and vaccination but should be used for all health and prevention services more widely.

Written by

Dr Cyril Eshareturi
Senior Project Manager: PHE London COVID-19 response

Dr Leonora Weil
Public Health Consultant: PHE London COVID-19 response

Julie Billet
Director of Operations: PHE London Operations