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By Dr Frank Atherton, Chief Medical Officer, Wales

(This article is based on a presentation to the Faculty of Public Health Conference in Telford on 20 June 2017 – view slides from the presentation)

Public health should be proud of the fact that we are an evidence-based profession. We have brought both the ethos and the tools of evidence-based clinical practice to the NHS and the wider public sector. However, we should not lose sight of the fact that public health is both a science and an art; this requires us to bring judgment to bear alongside evidence.

There are plenty of reasons that can be deployed in order not to use evidence. Sometimes issues can be seen as “blindingly obvious”; I recently saw a video of Brian Cox using the fact that we can actually see cosmic background radiation to energetically (and using colourful language) rebut a claim that the Big Bang is just a theory and may not have happened: “YOU CAN JUST ****** SEE IT.” As a newly qualified doctor on my first surgical firm, I worked with the team that had led the development of highly selective vagotomy as a curative treatment for peptic ulcer. In addition to the small operative mortality, many of the patients were left with long-term side effects such as malabsorption or diarrhoea. If I had dared to suggest that peptic ulcer might be a consequence of infection and amenable to curative treatment with antibiotics I would have been ridiculed, or worse. And yet this was subsequently found to be true and most patients are now successfully treated by H.pylori eradication rather than surgical intervention. The lessons I draw for my public health practice is that we should beware of our hidden prejudices and the influence of received wisdom; we should always be willing to challenge our assumptions. Other, less noble reasons for ignoring evidence include laziness, incompetence, pressure of work, and vested interests in outcomes; all issues that we should recognise and guard against as part of the ethical management of our own work.

Sometimes the evidence is rock solid but it is still not used to drive population health. The classic example must be smoking; we have known about the link between smoking and lung cancer since the work of Doll and Hill in the 1950s. But it took until 2007 for smoke-free public places to be enshrined in legislation across the UK. The 10-year anniversary of this achievement is an opportunity to recognise and celebrate its impact but also to raise the important question about where accountability lies for the thousands of avoidable deaths that have resulted from the decades-long delay in effective action. The answer seems to be “nowhere”. It seems to me that there is a failure in public sector governance if there is no accountability for inaction in the face of convincing evidence. The horrific events at Grenfell Tower perhaps serve as a more recent example.

And, of course, the evidence base is never complete, and we are often faced with contradictory evidence that steers us towards different courses of action. The recent debate about regulation of electronic cigarettes is a useful example. Evidence of the benefits as a smoking cessation aid have to be balanced by currently unquantifiable risks including the direct and indirect effects of vaping, and the potential for a new generation of young people to become addicted to nicotine. When faced with these sorts of uncertainty we have several options. We can commission further research, but that takes time. We can use a trial and error approach, but that brings risk (think of the death and illness last year of fit young volunteers in pharmaceutical trials in France). We can use a risk management and mitigation approach – something we all do unthinkingly in our daily lives when we buckle our seatbelts. And we can use a precautionary approach but, if used inappropriately, this might stifle innovation and change that could have a positive impact on population health.

Our approach in Wales has been to follow the thread of evidence-based public health action, from our research and development commitments (£43m per year), through the programme of action for our government, the legislative framework of the Wellbeing of Future Generations Act which requires public bodies to plan and report on population health outcomes, then through to our recently passed Public Health Act which has incorporated health impact assessment into our policy and planning. In Wales, we believe that evidence matters, but judgment and compassion also need to factor into our decision-making.

By Dr Jennifer Mindell, Reader in Public Health, Research Department of Epidemiology and Public Health, University College London

The government is proposing to ban the sale of diesel and petrol vehicles from 2040, to address air pollution in the UK that regularly breaches health-based EU regulations.

There are three main ways to improve UK air quality: reducing emissions from vehicles; driving less; and dealing with other sources of air pollution. The government’s preferred approach seems to be ‘business as usual, but less pollution from existing travel patterns’. Yet, even with this route, they are not committing to a scrappage scheme for diesel. This would produce air-quality benefits in the short-term, instead of in the 2040s – or even the 2050s and 2060s, as some individuals and businesses keep their vehicles for a long time. A scrappage scheme needs to be available to all individuals and businesses, regardless of size, and needs to encompass vehicles of all ages. Although older vehicles are known to be very polluting, no-one really knows about new vehicles! This could be complemented by financial help for retrofitting, particularly for older buses and lorries, if replacement isn’t an option.

Drivers of diesel cars are understandably aggrieved. They were urged to buy diesel engines by previous governments and given financial incentives to do so, because of the lower CO2 emissions per km. The higher emissions of other pollutants were ignored. Those with newer vehicles have no idea what their car really emits, due to the scandalous behaviour of manufacturers. This is yet another parallel with the tobacco industry (1) which designed cigarettes to produce low tar and nicotine in the laboratory but not when used by actual smokers.

Chargeable clean-air zones (low or ultra-low emission zones) are, according to a technical report issued by the government earlier this year, the most effective mechanism, but we understand that the government’s strategy will restrict charging to the last, not the first, resort. This is one of the areas, along with improved infrastructure for transport options other than private car use, that local authorities can contribute to greatly, but they need adequate powers and adequate resources. As air pollution costs the country £20 billion annually (2), the proposed figure of £255million to local authorities is a drop in the ocean.

The government is apparently also going to urge local authorities to speed traffic flows, by amending traffic-light settings and removing speed humps. What is actually needed is more calming, not less, to support smoother driving. It is not speed humps but the marked acceleration and braking that many drivers do that increases pollution. Greater use and enforcement of, and adherence to, area-wide 20mph limits without traffic calming would be better still.

Lower speeds, which would also support more and more pleasant walking and cycling, bring me to the better approach. Instead of persuading (in the next two decades) or requiring (from 2040) people to replace their existing car with an electric car, the health gains would be far greater if people travelled by public transport, walked or cycled whenever possible. As well as reducing pollution and carbon emissions, this generally increases physical activity and can improve wellbeing and reduce obesity and its consequences.

Reductions in pollutant emissions can also be achieved by reducing the need to travel. If people who could do so worked at home once a week, that would reduce their commuting by 20%. Land-use planning that encourages mixed use can shorten journeys sufficiently to make non-car options more feasible, although this will take longer. But as the government proposal for banning sales of diesel and petrol cars is to start in 2040, they are talking longer term anyway.

The government also needs to acknowledge that, although mobile sources are the largest category of pollutants, they are not the only ones. Two major contributors are buildings, including both homes and businesses, and transboundary industrial pollution from mainland Europe. Ministerial engagement with European countries will be necessary to deal with the latter. Local authorities need to be given the powers to address the former.
Air pollution is a major contributor to health inequalities. Poorer people are more likely to be exposed to higher pollutant levels. They are also more susceptible to the harmful effects of pollutants as they are more likely to have circulatory diseases (particularly heart disease and strokes) and respiratory diseases, such as chronic bronchitis or emphysema (now called chronic obstructive pulmonary disease) or asthma. Improving air quality is an important factor in reducing health inequalities.

The other option that we trust the government won’t take is to move the goal posts when (or if?) the UK is no longer bound by EU legislation. That would really be a cynical approach to the population’s health.

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1. Mindell J. Lessons from tobacco control for advocates of healthy transport. J Public Health Med. 2001; 23:91-7.

2. Royal College of Physicians, Royal College of Paediatrics and Child Health. Every breath we take: the lifelong impact of air pollution. London: RCP, 2016.

By Andy Beckingham FFPH, Fernandez Hospital, Hyderabad

Giggling Girls!

The scope of our profession gives opportunities to branch out. These may not always look at first glance like ‘public health’.

In 2010, working in India on maternal mortality, someone asked over dinner if I thought UK-style midwifery might be useful in India where doctors provided all the care. “Perhaps if you try the bits that work for women,” I said. “And avoid the bits that the NHS got so wrong.” My dinner companion turned out to be the MD of India’s most famous maternity hospital, and I found myself designing her midwifery pilot programme.

The midwife who had run the UK’s most woman-friendly midwifery service (the Albany Practice, which achieved great outcomes for disadvantaged women) was inveigled into joining us as a mentor. Eight anxious trainees found themselves becoming India’s first evidence-based woman-centred midwives (pictured). They began to develop their own profession, promoting choice about labour and supporting and empowering women to have more natural births. They had to challenge established obstetric practice. Our hospital’s maternity care began to change. Babies had been routinely separated from the mother at birth, although this impedes attachment and breastfeeding. The midwives worked with paediatricians to change that. Now most mothers have immediate contact and breastfeed their babies in the first hour.

Now leaders in their own right, those first eight have since mentored other trainees to become strong professional midwives, supporting thousands of Indian women to have better births.

Like most countries, India has unnecessarily high rates of intervention in childbirth. A local public hospital’s c-section rate is 52%. A local private hospital’s is 90%. But thanks to the midwives, ours has come right down. Instead of epidurals being routine, midwives ask women what pain relief they want. They offer choice. Women get continuity of care. The outcomes are better. Satisfaction rates are high.

In 2017, the state government invited us to train midwives to work in their hospitals too. They want c-section rates to come down. But they also want compassionate, respectful maternity care for the large numbers of women who are mostly ‘below poverty line’. So maybe, just maybe, this could become a model for wider public maternal-health improvement in lower-income countries. I have to assess its impact.

Designing a midwifery programme and curriculum doesn’t at first look like a public health role. But it is starting to address unmet needs, inequalities and disadvantage, improve care quality and effectiveness, show that Indian women and their choices matter. Of course, it will need to be part of wider action on social and economic determinants of maternal health.

And now, this alternative to the medical model is available, and the state government is actively promoting compassionate, effective midwifery care and supporting us to roll out professional midwifery more widely, among very disadvantaged women.

Public health, in disguise.

By Dr Justin Varney, National Lead for Adult Health and Wellbeing, Public Health England

Public Health England estimates that between 2-5% of the population identify as lesbian, gay, bisexual or other – comparable to many ethnic minority and faith populations. Despite legislative reform many LGBT people continue to experience discrimination, marginalisation and harassment.

  • 38 per cent of trans people have experienced physical intimidation and threats and 81 per cent have experienced silent harassment (e.g. being stared at/whispered about)
  • One in five (19 per cent) lesbian, gay and bi employees have experienced verbal bullying from colleagues, customers or service users because of their sexual orientation in the last five years
  • Almost 1 in 4 trans people are made to use an inappropriate toilet in the workplace, or none at all, in the early stages of transition. At work over 10% of trans people experienced being verbally abused and 6% were physically assaulted.

The impact of this discrimination on mental health is easy to understand, however the stark data on suicide and self-harm demonstrates the depth of the impact that this discrimination can have:

  • 52% of young LGBT people reported self-harm either recently or in the past compared to 25% of heterosexual non-trans young people and 44% of young LGBT people have considered suicide compared to 26% of heterosexual non-trans young people
  • Prescription for Change (2008) found that in the last year, 5% of lesbians and bisexual women say they have attempted to take their own life. This increases to 7% of bisexual women, 7% of black and minority ethnic women and 10% of lesbians and bisexual women with a disability
  • The Gay Men’s Health Survey (2013) found that in the last year, 3% of gay men have attempted to take their own life. This increases to 5% of black and minority ethnic men, 5% of bisexual men and 7% of gay and bisexual men with a disability. In the same period, 0.4% of all men attempted to take their own life
  • The Trans Mental Health Study (2012) found that 11% of trans people had thought about ending their lives at some point in the last year and 33% had attempted to take their life more than once in their lifetime, 3% attempting suicide more than 10 times.

The impacts aren’t limited to mental health, and the level of inequalities in lifestyle behaviours such as smoking and substance misuse will almost certainly play out in a great burden of chronic disease and premature mortality over the life course.

The evidence base of inequalities affecting LGBT populations continues to grow as we get better at incorporating sexual orientation and gender identity into the demographics of research and population surveys. Positively, as the NHS rolls out the sexual orientation monitoring information standard this year, this understanding will no doubt continue to grow.

As public health professionals we have a responsibility to advocate for the populations in our care, and this should include advocating for LGBT populations. Lesbian, gay, bisexual and trans communities are diverse, vibrant and varied and have many assets, although the LGBT community sector has faced fiscal challenges due to the economy there remain many small local LGBT organisations that are keen to work with public health teams to address these inequalities.  This is population who clearly need our professional expertise, advocacy and support to co-produce solutions for change and one where we could have a real impact.

So during this lesbian, gay, bisexual and trans Pride season please take up the opportunity to engage, empower and partner with your local LGBT community.

FPH is committed to improving the health and well-being of the LGBT population. If you would like to join us in our work please consider joining our Equality & Diversity Special Interest Group or our LGBT Health Special Interest Group. To express an interest in joining please email policy@fph.org.uk and we can help you get started!

Dr Alisha Davies, Head of Research and Development, Public Health Wales

We understand the importance of good quality, sustainable employment for health. We also recognise that economic shocks, such as the loss of a high number of jobs in a localised area, can have a detrimental impact on the health, social and financial situation of individuals. In the years following a mass unemployment event workers can experience double the risk of death from heart attack or stroke and even greater increases in problems such as alcohol related disease, alongside detrimental effects on mental health. The impact can extend beyond those directly made redundant to families, local communities, and the effects endure over many generations.

Preparedness to address the health consequences of mass unemployment events is of national and international importance – yet there is very little information on how to better prepare and respond to such events. The public health discipline has emergency planning response frameworks for other events, such as flooding, which have a significant impact on individual and community health, but not mass unemployment.

Working with academic experts and those previously involved in public health responses to mass unemployment events across the globe – from the motor industry in Australia, to mining in New Zealand, Public Health Wales have developed a basic framework to support public, voluntary and private sectors with prevention, planning for and reaction to mass unemployment events.

The recently launched report provides an eight-step framework to support public, voluntary and private sectors with prevention, planning for and reaction to mass unemployment events. Key priorities where public health approaches can help are highlighted including early identification of areas at risk; ensuring the reactive responses address the health and wellbeing needs of all those affected alongside financial and re-employment advice; providing accessible support for families, and the wider community – in particular vulnerable groups, such as the long term unemployed; and increasing awareness through community and third sector links.

Preventative measures identified by those interviewed included longer term consideration of skills development, investment and diversification, social responsibility of employers announcing redundancies, and increasing individual and community resilience.

This report is an important tool to inform action to help prevent and minimise the consequences and harms of mass unemployment events (MUEs) to population health. The work was taken forward following events in Wales, but has national and international reach across many European and International countries.

NOTES:
The report and info-graphic will be available on the day of launch in English and Welsh, and it will be announced on our Public Health Wales website on Friday 30th June (www.publichealthwales.org).

By Hannah Dorling, Helen Walters and Tara Lamont

How can alcohol licensing decisions impact upon alcohol-related crime and health issues? Does turning street lights out at midnight cause more accidents? How does a new bus service impact upon physical activity levels?

Front-line public health professionals need relevant evidence in formats that reach them and are digestible by them and those they work with. At this year’s FPH conference we are running a session on just this issue. The National Institute for Health Research (NIHR) spends £10m a year on its Public Health Research (PHR) programme and we are one of the main funders of public health research in the UK. We support research which may not be funded by others – from studies of impact of alcohol licensing to evaluation of urban motorways. NIHR also runs the Dissemination Centre whose specific role is to get research findings to the front line.

We want to fund research that evaluates public health interventions that happen outside the NHS – that will provide new knowledge on the benefits, costs, acceptability and wider impacts of interventions that impact on the health of the public and inequalities in health. We want this research to be multi-disciplinary and broad, covering a wide range of public health interventions. Funding comes from the Department of Health in all four UK countries. A key aim of the programme is to deliver information to allow practitioners and policy makers to improve services, rather than simply improving scientific knowledge. A challenge for the programme is finding the questions that most urgently need answering.

We also need to help decision-makers get hold of the evidence they need. Every day, about 75 new clinical trials and 11 new systematic reviews are published, many of which will be relevant to public health. The NIHR Dissemination Centre filters new knowledge and produces a wide range of publications. We want to know more about what kinds of evidence and formats work best for front line staff.

This is where we need you. This interactive conference session is aimed at front-line public health professionals (though academics are welcome!) who want to talk about how you use research in your daily work. Where do you find your research? What do you do with it? What would you like more of? Do you have challenges linking to the academic world? What questions would you like answered to help you in your work? Come along to our session and tell us what you think. We are keen to hear and to use your wisdom as we reflect on 10 years of public health research funding and make plans for the next 10 years.

In the meantime if you have an idea for research that needs doing please do contact us on phr@nihr.ac.uk or use the programme’s online mechanism for submitting suggestions.

Join the session at the FPH conference on Tuesday 20 June in Telford:
11:30 – 12:30: Public health need – filling the evidence gaps in local government
Location: Wenlock Suite 1&2
Presenters: Helen Walters, Consultant in Public Health Medicine / Consultant Advisor, NIHR NETSCC, University of Southampton
Tara Lamont, Deputy Director of the NIHR Dissemination Centre
Closing comments: John Middleton, President of the Faculty of Public Health

By Elizabeth Orton

The Faculty of Public Health’s Transport Injury Prevention Network will be holding an inaugural workshop at the FPH conference in Telford on 20 June.

As well as introducing the aims and objectives of the network, the session will focus on speed reduction as a key road danger reduction strategy. We will be looking at how to improve collaboration in local government between public health and transport teams to encourage active travel and reduce road danger. We will review the evidence around 20mph zones and limits and discuss strategies for their implementation, sharing examples of good practice, tools and approaches.

Please come along and share your ideas, experiences and views with us.