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isabella-goldie

  • By Isabella Goldie

  • Director of Development and Delivery

  • Mental Health Foundation

There are times throughout all of our lives when we are likely to run into difficulty, particularly at life’s pressure points: the crucial times of transition from one life stage to another. From moving away from home for university, to having children or dealing with the loss of a loved one.

If we are to rise to the challenge of reducing the prevalence of mental health problems, we need to be stepping in at these pressure points, taking preventative measures that can support people through times of difficulty and stop mental health problems from developing in the first place.

This will require a societal shift. We will need to begin truly recognising good mental health as a universal asset to be strengthened and protected. We can no longer afford to wait for mental health problems to develop before taking action.

The effective support of people experiencing mental health problems is set to become one of the greatest public health challenges of this decade. Without action on the increasing demand for public services, it will not be possible to absorb the rising costs of providing care and support for those experiencing mental ill health in the long term. We need to act decisively as we have in the past when faced with significant risks to public health.

It is essential that we also draw our attention to preventative approaches so that illness is a rarer event.

The historical approaches to curing illness and responding in crises has left a legacy of health services designed to fix problems. While access to good quality mental health services and support must continue to improve and rapidly, it is essential that we also draw our attention to preventative approaches so that illness is a rarer event, both in recognition of the economic costs and also in the sometimes devastating personal impact resulting from poor mental health and mental health problems.

Last week the Mental Health Foundation published Mental health and prevention: taking local action for better mental health, a report produced with Public Health England which lays out a road map for bringing about a prevention revolutio

n in mental health, delivered in every local area. In addition to the strong theme of mental health across the life-course, taking every opportunity to step in early and prevent the development of mental health problems, the need to improve the mental health knowledge and literacy of the entire public service workforce is highlighted.

Integrating mental health improvement into daily work

This radically different approach encourages all health and social care staff to consider the impact of mental health inequalities and act to reduce them. Staff must react to these inequalities in line with the principles of ‘proportionate universalism’, an approach that progressively applies resources where the greatest risks lie.

In practical terms, this means integrating mental health improvement into daily work, with messages and interventions tailored to meet specific needs of those at highest risk of developing mental health problems.

We need to ensure that high-quality services are both available and easily accessible for those that need them most, while also intervening early to reduce the need for specialist support. We can achieve this by giving individuals, families and communities, the tools to protect and manage their own mental health.

This will only ever be achieved by working alongside communities, listening to people’s stories of lived experience to understand what impacts their mental health and what tools they need.

  • by Bayad Nozad, FFPH
  • Co-chair, FPH’s Global Violence Prevention SIG

Air pollution is a serious public health issue and high on the agenda now. Last year, the Department for Environment, Food and Rural Affairs (Defra) and Public Health England (PHE) collaboratively produced guidance to ensure evidence based actions are taken nationally and locally to improve air quality.

The WHO guidelines states that that there are no safe levels of the main pollutant of concern, Particulate Matter (PM), and impacts on air pollution are observed below levels permitted by EU and UK limits (1). The guidance also states that for long term exposure (over months or years) the levels should not exceed annual average concentrations of PM of 10 μg/m3 of PM2.5 and 20 μg/m3 of PM10 (2):

There is now mounting evidence that long term exposure to air pollutants contributes to the development of lung cancer, cardiovascular disease and respiratory illness. The Department of Health’s (DH) Committee on the Medical Effects of Air Pollutants (COMEAP) estimated the burden of PM air pollution in the UK to be equivalent to nearly 29,000 deaths and an associated loss of population life of 340,000 life years lost (3).

It is not disputed that military conflicts are associated with massive release of pollutants into the environment including air. The war in Iraq associated with hundred thousand tonnes of pollutants from military vehicles and weaponry that continue to adversely affect the public’s health.

A great legislation that contributed to limit the environmental damages from industry is the Polluter Pays Principle (PPP). The PPP is a well-established National, European and International code through which the costs of pollution prevention and control measures should be paid by polluter.

The preventive function of the PPP which is based on the assumption that the polluter will reduce pollution as soon as the costs which he or she has to bear are higher than the benefits anticipated from continuing pollution. The control measures should be decided by public authorities to ensure that the environment is in an acceptable state (4).

In applying the above principle to the war in Iraq, it would be useful to know how much consideration had been given to the air quality and the PPP in the decision making process to invade Iraq. It is less likely that this was an issue for the decision makers but would they now face the consequences and take responsibility to clean up the mess, in particularly following the publication of the Chilcot report?

Further, the health impacts from air pollution are not limited to the residents of the affected area but also to serving military personnel. This should be highlighted to new army recruits as occupational hazard and measures should be taken to reduce the adverse effects.

child at water fountain
Future generations in Iraq and conflict zones need access to clean water

More research is needed to quantify the war-related environmental pollution as a considerable potential contributor to Iraq’s poor health conditions and high rates of mortality from CVD and cancer.

For the sake of future generations of Iraqis and others growing up in former conflict zones, we cannot let winning the peace be at the expense of access to clean water as well as good air quality and health.

References
(1) Review of evidence on Health Aspects of Air Pollution – REVIHAAP: final Technical Report, World Health Organization Office for Europe, 2013
(2) WHO air quality guidelines global update 2005, World Health Organisation, 2005
(3)  The Mortality Effects of Long-Term Exposure to Particulate Air Pollution in the United Kingdom A report by the Committee on the Medical Effects of Air Pollutants, 2010
(4)  ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT (OECD), THE POLLUTER-PAYS PRINCIPLE Analyses and Recommendations, ENVIRONMENT DIRECTORATE, Paris 1992

  • by Marguerite Regan
  • Policy Manager, Mental Health Foundation

One in four of us will experience a mental health problem each year, representing the largest single cause of disability in the UK. As it stands, the economic and social costs of poor mental health (estimated at £105 billion a year) are too great for our health and social care systems to handle.

We need to invest in upstream interventions in the places where people live, learn, work and play. It is imperative that a public health perspective is taken within mental health to change the current crisis and reactive service model.

The mind-body division has historically mean that public mental health has been a neglected field and perceived to be outside the remit of public health.  The Faculty of Public Health chose to focus on the mental health agenda, making it the core theme of their annual conference this year and collaborating with the Mental Health Foundation to combine expertise and produce some key resource aimed at supporting the development of knowledge and skills in public mental health.

Better Mental Health For All cover

Better Mental Health For All report

The resources include a report, three videos and a Public Mental Health Award. Over 600 copies were distributed to delegates at the Brighton-held conference.

The report examines what can be done individually and collectively to enhance the mental health of individuals, families and communities by using a public health approach and looks to support the development of knowledge and skills in public mental health. The report is an evidence based resource for people who want to create real change in local communities.

It outlines the critical role that public health professionals, commissioners and elected representatives play in leading the necessary reforms. The report gives clarity to the fact that we know how much can be done to promote mental health and wellbeing across all age groups, prevent mental health problems from occurring and to support people to recover their mental health.

Throughout the report, case studies showcase examples of innovative public mental health programmes and projects being run across the UK. These were selected from the thirty entries submitted to the Faculty of Public Health inaugural 2016 Public Mental Health Awards and celebrate the public health professionals who are pioneering role models for public mental health.

Three of these case studies were then chosen to have their work presented in short videos, which were launched at the conference. These three varied examples illustrate clear advocacy for public mental health by public health practitioners, exploring; A mens mental health/suicide prevention project in Torbay;  a project addressing mental wellbeing as part of flood response in Somerset;  and social prescribing in Lanarkshire.

The public health professionals involved in these, and several of the other case studies, were invited to share best practice at two sessions held during the conference. It should be noted that these particular sessions were hugely popular with delegates, illustrated by the room being well over capacity.

FPH’s focus on highlighting public mental health this year was largely driven by outgoing President, Professor John R Ashton CBE. He spoke at length about mental health during the conference and awarded the Faculty’s inaugural Public Mental Health award to Gerry Cadogan, Public Health Principal at Torbay Council, for the Torbay men’s mental health/suicide prevention project. Mental health ran through the whole conference, with the keynote given by Dr Stan Kutcher on increasing mental health literacy of young people.

Collaboration is central to the pursuit of good mental health across society. It is vital that both public health practitioners and mental health professionals become advocates for public mental health to prevent mental health problems and promote mental wellbeing.

This isn’t to say that full responsibility lies with them, and governmental-level action and support is also required. It is our hope that this partnership between the Mental Health Foundation and the Faculty of Public Health will encourage more leadership and advocates for public mental health across the UK.

  • By Dr Sandra Davies, Director of Public Health, Liverpool City Council
sugar cubes image

Sugar Cubes campaign

 

Most of us think we know the basics about sugar. We know that there is likely to be a lot of sugar in a chocolate bar and less so in a yoghurt. It’s obvious, right? But are we as sugar savvy as we think?

A lot of the sugar we consume isn’t as obvious as we think. Many sugars consumed by families and children come from products that you wouldn’t necessarily expect to have much sugar in them; so called ‘hidden’ sources. Did you know that, on average, there are nine sugar cubes in a can of cola, over five sugar cubes in a sugary yoghurt and six sugar cubes in a chocolate bar? Yet the maximum added sugar intake for four to six year olds should not be more than five sugar cubes per day. There are also lots of hidden sugars in tomato sources, flavoured water, soups and lots of other unexpected items.

One of the problems is that many of us don’t study or understand food labelling. To help us get to grips with it all, Change4Life launched a campaign back in January to help parents and families to become more Sugar Smart and cut back on the amount of sugar in theirs and their children’s diets. The campaign revealed the surprising amounts of sugar in everyday food and drinks and encouraged families to take control and protect their children from the dangers of having too much sugar.

The campaign also advised  on the maximum amount of sugar we should be having each day as recommended by the government and promoted the new Sugar Smart app. The app is a brilliant tool, completely free to use and  download,  designed to show quickly and easily how much total sugar is in the things you’re buying, eating and drinking and to help you spot it more easily so you can make healthier choices. You can just scan any barcode in your supermarket shop and it tells you how much sugar is in the item.

The campaign followed on from the successful Food Active GULP Campaign (Give Up Loving Pop)  supported by North West Directors of Public Health which highlighted fizzy drinks as the biggest culprit in the fight against sugar in the diet of children and young people.

Liverpool Public Health and Liverpool City Council supported both of these campaigns locally which then further alerted us to the size of the health problems related to high levels of sugar in the diets of our children and young people. There are alarming levels of tooth decay in young children in the city, with dentists having to remove teeth from children as young as five under general anaesthetic on a daily basis, and around 2,000 children in the city will have had extractions by the age of five.

More than a third will have suffered from tooth decay.  What’s most shocking, is that tooth decay in particular, in children, is largely preventable by reducing sugar intake and keeping teeth clean. Also, what many people don’t realise is that baby teeth help guide adult teeth into position and persistent infections. Loss of baby teeth can also lead to further problems with the development of the adult teeth in the future.

Rates of overweight and obesity reported through our National Child Weight Measurement Programme were also a real cause for concern, and with research suggesting that children are consuming three times the recommended daily allowances of sugar, largely through sugary drinks, we felt that we had to take some really strong action. As a parent myself, I know how important it is to get children into good habits early on. Whilst many of us might relate too much sugar to a sore tooth or putting on a bit of weight, it can also lead to tooth decay, obesity, diabetes and some cancers in the future.

The Change4Life campaign highlighted the fact that parents found that the labelling on drinks was confusing. Knowledge is half the battle and so we decided to develop a campaign that would clearly display the amount of sugars in drinks popular with children.
We are very fortunate in Liverpool to have an Insight and Behaviour Change team that works with every aspect of public health to come up with creative and outcome driven initiatives.

We decided to go one step further than with previous campaigns, launching our ground breaking ‘Sugar cube campaign’ which shows how much sugar is in popular branded children’s drinks. For the first time, branded drinks, including Lucozade, Capri Sun and Coca Cola, are  explicitly named to show how many cubes of sugar each bottle contains.

The campaign launched on 9th May, and is aimed at families and parents of children aged 5-11. So we could influence this group, we placed campaign materials in areas where we expect parents to visit (e.g. children’s centres, hospitals, dental practices, GP practices, walk in centres etc).

Parents are being encouraged to swap their children’s sugary drinks for water, low fat milk and diet drinks and if they still choose sugary drinks they are advised to keep them to meal times only. As well as displays there will be a range of local family fun community events and regular items on radio. We’ve also used interviews in the local media with local dentists and councillors who are supporting the campaign.

sugar cubes image 2

The hidden sugars in everyday drinks

The campaign will run over the summer, and will be fully evaluated for impact and awareness. We will measure the number of local hits and sign ups to the Change4Life website, the number of hits on the Liverpool Echo digital adverts, twitter engagement  and engagement at the community events. The Campaign has already attracted a great deal of media interest, locally, regionally and nationally, and has led to many requests from other areas of the country who have asked to use the materials to bring this very important message to their own localities.

In developing the communications plan the Insight and Behaviour Change Team in Public Health  worked with the Communications team at the Local Authority, and put together a team of spokespeople and health professionals available for media interviews. This included myself as DPH, the Elected Member for Health and Social Care and The Mayoral Lead for Health and Wellbeing and Consusltant Paediatric Dentists.

Whilst we did expect some media interest, given some of the startling facts that we were presenting, the level of interest up to and on the day of the launch was extensive. The fact that I as DPH was able to front a lot of the media is really testament to the relationship that we have with our Elected Member and mayoral lead for health and wellbeing, and how public health has been supported within the Council as a whole. Whilst it was great as DPH to be a voice for the campaign, it was important that we had Elected Member voices and other health professionals  to add weight to the stance that the Council was taking.
For more information on the Sugar Cubes campaign  please contact Katy.Simic@liverpool.gov.uk

Allemani_Claudia05

Dr Claudia Allemani

  • by Dr Claudia Allemani, PhD FHEA MFPH
  • Senior Lecturer in Cancer Epidemiology, Cancer Survival Group, London School of Hygiene & Tropical Medicine

In March 2016 I was delighted to receive a letter from Professor John Ashton, President of the UK’s prestigious Faculty of Public Health (FPH), congratulating me on being awarded FPH’s inaugural Global Public Health Award.

I was really happy. In a period during which finding support for public health research is becoming more and more challenging, this award gives me one more reason to pursue my professional goals.

My interest is in international comparisons of population-based cancer survival – much cheaper but far less sexy than clinical trials or molecular biology studies. Clinical trials are the gold standard for testing the efficacy of new treatments by randomised assignment of eligible patients, but they recruit patients selected on criteria of age, stage, co-morbidity, etc.

Population-based cancer survival is the gold standard for public health. It reflects the survival achieved for all cancer patients, regardless of their age, health status, stage of disease and access to care, and after eliminating the risk of death from causes other than cancer. It is a key measure of the overall effectiveness of health systems in the delivery of cancer care.

This award is a great professional honour for me personally as a public health scientist, but it is also an authoritative recognition of the global public health contribution made by the CONCORD programme, the 67-country collaboration that established world-wide surveillance of cancer survival in 2015 (The Lancet).

It also gives me a great opportunity to inform the UK public health community about this unprecedented enterprise, which I have the privilege to lead.

Concord logo

CONCORD: 67-country collaboration

The CONCORD-2 study provided estimates of 5-year net survival for patients diagnosed during 1995-2009 with one of 10 common cancers. We analysed data on 25.7 million individual cancer patients, contributed by 279 population-based cancer registries in 67 countries, 40 of which with 100% national population coverage. The CONCORD Working Group included 496 collaborators.

The Lancet article on CONCORD-2 was covered by 170 TV, radio, press and wire outlets world-wide, with intensive social media attention (Altmetric 770, above 99.98% of 4.8 million articles). Results have now been included in the American Cancer Society’s Cancer Atlas and the Global Lung Cancer Coalition atlas. The article has been downloaded over 43,000 times and cited over 270 times in the first 12 months.

Population-based cancer survival is used by policy makers to plan future cancer control strategies. The US Center for Disease Control and Prevention described CONCORD-2 as the start of global surveillance of cancer survival, with survival estimates “that can be compared, so scientists can begin to determine why survival differs among countries. This could lead to improvements in cancer control programs.”

This has already started. In July 2015, CONCORD-2 results were used to inform England’s new cancer strategy, Achieving world-class cancer outcomes: a strategy for England 2015-2020. In September 2015, the International Atomic Energy Agency’s Programme for Action on Cancer Therapy (PACT) used the results to drive an ambitious world-wide campaign to highlight the global divide in cancer survival, and to raise awareness of persistent inequalities in access to life-saving cancer services.

These unprecedented results still seem insufficient to convince some local charities to support this kind of scientific research, even if is instantly recognised as important by cancer patient bodies such as the European Cancer Patient Coalition, the European Cancer Leagues and national cancer patient associations from Argentina to Poland, Switzerland, Japan and the UK.

FPH’s independent judgement in giving this award for my work on the CONCORD programme may help to persuade these charities that to support global research also means supporting global research in their own country!

I am particularly delighted that this award has been made to an Italian cancer epidemiologist during the run-up to the European referendum – it gives me great pleasure to recognise the open-minded vision of public health professionals in the UK.

We have now issued the data call for CONCORD-3!

 

  • by Lorraine Lighton, outgoing CPD Director at FPH

As my term as Director of Continual Professional Development (CPD) for FPH draws to a close, I’ve been reflecting on how the FPH CPD scheme has developed during the last four years and how much I’ve learned about the process of continuing professional development.

There have been substantial changes to the CPD policy and guidance in recent years to make it fit for now and the future. None of this could have happened without the amazing support of the Faculty staff, especially Krisztina, Audrey and James, and the CPD Advisers who work with me to develop policy and guidance and who act as auditors.

One of the highlights of my time in office has been the development of guidance on writing reflective notes. This was produced by a small sub-group of CPD Advisers and has been commended by the General Medical Council.

Why do we place so much emphasis on reflective notes? One of the great strengths of the FPH CPD policy is that it recognises that there are many ways of learning, not just attendance at training events where certificates are handed out. Because FPH accepts such a wide range of activities as CPD, for which formal evidence such as test results or certificates are not available, we need a different form of evidence and that is what reflective notes are partly about.

They have the added bonus of making us think about the activities we have undertaken, what we learned from them, how our practice may change as a result, and what further learning we may need, thus developing us as reflective practitioners. Members of the FPH CPD scheme will recognise that this is the basis for the ‘Four Questions’ on the CPD record.

FPH audits a selection of CPD records every year as part of its quality assurance. As Director of CPD, I am that scary person who makes the final decision if an audit submission is deemed unsatisfactory. I know how it feels to be audited and the anxiety of waiting to find out if you have ‘passed’. We have responded to members concerns by speeding up the audit process and bringing it forward, so that members have plenty of time to improve their documentation for the following year if they didn’t meet the standards.

Although auditing is a substantial workload, it is never boring and has given me an overview of where members who struggle with CPD documentation go wrong. Here are my top ten tips to getting it right:
1.    Read the CPD policy and guidance. It’s not a difficult read and will help you understand exactly what is required and what to do if you are having problems.

2.    Ensure that your Personal Development Plan is broad enough to cover a substantial amount of your CPD for the following year, but sufficiently focused that there is more than one line such as ‘Do CPD’. And yes, PDPs like that do exist.

3.    If you are having difficulty undertaking sufficient CPD (maybe you need help recognising that some of your on-the-job learning can be claimed), seek help early!

4.    If you have problems recording your CPD, seek help early! Don’t wait until the end of the CPD year to suddenly find that you don’t know how to use the online log, your written English is insufficient to write a few sentences about your experience of learning, or you haven’t had time during the year to record your CPD or develop a Personal Development Plan.

5.    FPH has a fantastic team of administrators and CPD Advisers who can direct you to guidance and if necessary find solutions, but you need to seek help early as soon as you identify a difficulty, not after you receive the dreaded letter advising that you have been selected for audit.

6.    You don’t have to be Proust to write a reflective note. We don’t need volumes of high literature. Have a look at the examples on the FPH website, which includes my own submission for audit (and I was always near the bottom of the English class at school). When composing a reflective note, I say it to myself as though I were talking to a colleague then write it down verbatim, but do whatever works for you.

7.    On the other hand, it is not really possible to show reflection in a note comprising less than 20 words in total for answers to all four questions. If you are unsure how to write a reflective note, read the guidance on the FPH website.

8.    Please don’t feel insulted by comments from the auditors. These are intended as a pat on the back (for high quality documentation) or as constructive criticism if there is room for improvement.

9.    Please don’t complain to the Faculty because you have been selected for audit two (or three or more) years in a row. In order to ensure quality control there has to be a random element to the selection, so some people will hit the jackpot more than others. We have made submitting for audit as easy as possible – you just need to click on the submit button. And if you have been keeping up to date with writing reflective notes, the whole process of submission should only take a few seconds.

10.    If your documentation is assessed as unsatisfactory at audit, DON’T PANIC. Follow the guidance from the auditors and you will almost certainly ‘pass’ next time.

The most important thing I’ve learned during the last four years is that CPD should not be seen as an unwelcome hurdle. The Faculty CPD scheme aims to help us become the best practitioners we can. So next time you are selected for audit, be pleased you are being given a chance to show off your reflections to your peers!

  • by Allyson Pollock, Professor of public health research and policy at Queen Mary University of London.

On 2nd March 2016, along with 70 other academics, doctors and public health professionals, I wrote an open letter to Ministers of Health, Education and Sport, Chief Medical Officers and Children’s commissioners in four nations of the UK, as well as the Republic of Ireland. We asked them to consider the evidence and remove the collision elements of rugby within British school systems, so that children play touch and non-contact rugby.

The UK government has selected rugby union and rugby league as two of five sports it will focus on to increase the prominence of competitive sport in schools It hopes to put 1,300 links in place between schools and rugby union organisations, and 1,000 links with rugby league, and wants to recruit one million school children to the game in England across 750 State Schools.

Our concern is that rugby is a high-impact collision sport with a high rate and risk of injury. Although there is no comprehensive injury surveillance in the UK, studies show that the risk of injury for a child rugby player varies from 12% to 90% over a season of 15 games, depending on the definition used.

A systematic review puts the average risk of injury at around 28%. These injuries include fractures, ligamentous tears, dislocated shoulders, spinal injuries and head injuries which can have short-term, life-long, and life-ending consequences for children.

The risk of concussion for a child or adolescent rugby union player over a season is 11% – that’s the equivalent of one or two players sustaining a concussion every season in every school or club rugby team of 15 players.

Contact is where the majority of injuries occur. Research also points to the tackle being a particular cause for concern. In studies of youth rugby, tackles were found to be responsible for up to two thirds of all injuries and 87% of concussions.

Given that children are more susceptible to injuries such as concussion, the absence of injury surveillance systems and primary prevention strategies in the UK is worrying. For far too long. The Rugby Unions have chosen to hide behind the lack of comprehensive nation wide data citing this as insufficient evidence meanwhile ignoring the evidence that has been collected over decades.

The four rugby unions of England, Scotland, Wales and Ireland have responded to concerns and criticisms with many initiatives, including concussion management protocols, but none have been evaluated. Furthermore, these initiatives are concerned with management of injury and not prevention and comprehensive injury surveillance has been relatively neglected.

Editor-in-chief of the British Medical Journal, Fiona GodleeEditor-in-chief of the British Medical Journal, Fiona GodleeEditor-in-chief of the British Medical Journal, Fiona Godlee, has called the current state of monitoring and prevention of rugby injury in schools a “scandal” and last year a BMJ poll of doctors confirmed that 72% felt the game should be made safer.

Injury prevention requires radical changes to the laws of the game. It means removing the collision element, namely the tackle. Martin Raftery, the medical director of World Rugby has stated that the laws of rugby may have to change to reduce concussion risk, but World Rugby is dragging its feet in dealing with the dangerous tackle.

The key problem is that it is the sport’s own governing bodies that determine the laws of the game for children. World Rugby determines the laws even at school level but its interests are in the professional game and business, not children. The link between the professional game and the children’s game should be severed – governance of the children’s game should not be determined by World Rugby and the Rugby Unions.

If the game is rolled out to one million school children in England, and the tackle and collision remains a part of the game, children will be left exposed to serious and catastrophic risk of injury, and on the basis of current studies the potential number of avoidable injuries could rapidly approach at least 100,000-300,000 a year.

Parents expect the state to look after their children when they are at school, they do not expect their children to be injured. However, neither parents nor children are given information on injury risks and causes in this sport.

Even more worrying is the fact that many secondary schools in the UK deliver contact rugby as a compulsory part of the physical education curriculum from age eleven – children and their parents do not have the option to opt out of a situation that risks bringing them serious harm.

Children who want to play the tackle version can always join a club, but they shouldn’t be forced to play contact rugby as part of the national curriculum when there is such a significant risk.

As a signatory to the UN Convention on the Rights of the Child, the UK and Irish governments now need to take all necessary steps to inform children and protect children from mental and physical injury and abuse and ensure the safety of rugby.  Injury surveillance and monitoring in hospital emergency departments and by schools must be a priority so that data on sports and other activities can be collected. Until the government can show that harms and injuries have been minimised it should remove the contact from the children’s game in schools.