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By Daniel Flecknoe, Co-Chair of the FPH Global Violence Prevention Special Interest Group

The preliminary report of the Lancet/American University of Beirut Commission Health workers and the weaponisation of health care in Syria [Fouad et al, 2017] was published on 14 March, calling attention to the principles of medical neutrality and unhindered patient access that have been so badly neglected in the ongoing Syrian conflict. Systematic targeting of health workers by ISIS, Syrian and Russian military forces is a war crime committed against civil society, and epitomises a disturbing trend of indifference and impunity to international humanitarian law by warring governments and armed groups over recent years. Established norms in the conduct of war, built up over the past century and a half since the founding of the International Committee of the Red Cross, may be irrevocably degrading, and the public health consequences for civilian populations exposed to such deliberate brutality will be correspondingly more severe.

The Faculty of Public Health’s (FPH’s) Global Violence Prevention Special Interest Group (SIG) is committed to engaging with this neglected and worsening cause of preventable morbidity and early mortality. Its members contribute to research into the health impacts of armed conflict (including the Lancet paper referenced), engage and collaborate with other conflict-prevention organisations and conduct advocacy for arms control, economic/democratic reforms, and respect for human rights and the rules of war. We encourage all public health professionals to give parity to armed conflict along with other major global causes of illness, injury and death, and to lobby (both as citizens and medical professionals) for foreign policies that will protect and preserve health.

The SIG will be represented at the FPH conference in June, and members will be happy to discuss our current workstreams with anyone who might be interested in getting involved.

References:
Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, El Arnaout N, Bou Karroum L, Jawad M, Roborgh S, Abbara A, Alhalabi F, AlMasri I,  Jabbour S. 2017. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria. The Lancet. Published online 14/07/17 http://dx.doi.org/10.1016/S0140-6736(17)30741-9

By Professor Aileen Clarke, President of the Society for Social Medicine

A highlight of this year’s UK Faculty of Public Health Conference in Telford is going to be the Society for Social Medicine’s (SSM’s) ‘Research in Action’ session.

The SSM will be hosting this research feast at the always fantastic and hugely enjoyable FPH conference. Last year this session had standing-room only and this year it will be bigger and better than ever – and hopefully will have more chairs!

In our ‘Research in Action’ session, we will be presenting the top-scoring abstracts from SSM’s own annual scientific conference with a variety of public health topics. Last year they ranged from obesity, to housing and health and active commuting. This year we’re including public health advocacy, youth mentoring and immunisation uptake.

You can also expect the presentations to cover a range of research methodologies from epidemiology, cost-effectiveness modelling, systematic reviews and mixed methods to qualitative research.

SSM’s purpose is “advancing knowledge for population health” and in this case we are hoping to advance knowledge by showcasing exemplar public health research. Our session at the FPH conference is an exciting opportunity to promote linkages and future collaborations between public health researchers and practitioners.

I hope I have been able to sell our session to you. Please do come along and get involved.

Please find more information about the FPH conference at Telford on 20-21 June here.

By Ben Barr, Senior Lecturer in Applied Public Health Research, University of Liverpool, and Lee Bentley, Research Associate, University of Liverpool

The Chancellor of the Exchequer is due to deliver this year’s Budget on Wednesday. It is imperative that he provides additional financial support for disabled people affected by the planned cuts to Employment Support Allowance (ESA) – or risk further widening the disability–poverty gap.

One in three working age disabled people are living in poverty. Their risk of poverty is one and a half times greater than for people without a disability. The government’s strategy, however, for improving the lives of disabled people, focuses almost exclusively on the disability-employment gap rather than this disability-poverty gap (1). It is true that the high risk of poverty amongst disabled people is largely because they are less likely to be in work and supporting people into employment is an important strategy for reducing poverty. Welfare benefits, however, also play a crucial role in preventing poverty by limiting the loss of income people experience when they can’t work due to disability.

People who have lost their jobs because of a disability are likely to be out of work for longer than people who become unemployed. For this reason, disability benefits have generally been set at a higher level than unemployment benefits. From April, this will no longer be the case. The government is reducing the level of ESA for disabled people who are assessed as being currently unable to work but potentially capable of work at some time in the future. The benefit will be reduced by 30% to £73 a week – the same level as unemployment benefits. But whilst 60% of new claimants of unemployment benefits will move off the benefit within six months, 60% of people on ESA will still be claiming this benefit two years later (2). This means that many people out of work because of a disability will have to survive for long periods of time without an adequate income.

Levels of poverty are already very high amongst people out of work with a disability and have been increasing since 2010, particularly amongst people who have a low level of education – the group most reliant on disability benefits (see Figure 1). Cutting these benefits will exacerbate this adverse trend.

Percentage of people with disability in poverty

FIGURE 1: % of people with a disability in poverty, aged 16-64, between 2007 and 2014, by employment status and educational level 

The government argues that reducing these benefit levels will incentivise disabled people to stay in or return to work (3), but there is little evidence to support this assumption (4), and some that suggests it may reduce their employment chances (2). Strategies to reduce the disability-employment gap over recent decades have increasingly focused on more stringent assessment criteria for disability benefits, reduced payment levels and requiring claimants to do more to prepare for work or risk losing their benefits (5, 6, 7). These strategies have had little impact on the employment of people with disabilities (8). It remains to be seen whether the government’s new strategy to halve the disability employment gap will be any more successful (1).

Even if the government’s strategy does improve the employment of disabled people, it is likely this will disproportionally benefit disabled people with greater skills and education (9, 10). The planned cuts in ESA will increase the risk of poverty for the most disadvantaged disabled people who remain out of work, and this may increase the disability-poverty gap.

Increasing poverty amongst people out of work with disabilities will adversely affect their health and increase health inequalities. We know that poverty damages peoples’ health, and adequate welfare benefits for people who can’t work can reduce these effects (11). We have seen that in recent years inequalities in health are increasing (12) in part due to disability benefit reforms (13). The severe cut planned by the government will further exacerbate these inequalities, potentially increasing levels of disability.

1    Great Britain, Department for Work and Pensions, Great Britain, Department of Health. Improving Lives: The Work, Health and Disability Green Paper. 2016 (accessed March 2, 2017).
2    Work and Pensions Committee. Disability employment gap. London: House of Commons, 2017 (accessed March 2, 2017).
3    Kenedy S, Murphy C, Keen K, Bate A. Abolition of the ESA Work- Related Activity Component. House Commons Libr Brief Pap 2017.
4    Barr B, Clayton S, Whitehead M, et al. To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems. J Epidemiol Community Health 2010; 64: 1106–14.
5    Watts B, Fitzpatrick S, Bramley G, Watkins D. WELFARE SANCTIONS AND CONDITIONALITY IN THE UK. York: Joseph Rowntree Foundation, 2015.
6    Banks J, Emmerson C, Tetlow GC. Effect of Pensions and Disability Benefits on Retirement in the UK. National Bureau of Economic Research, 2014 (accessed Sept 26, 2015).
7    Baumberg B, Warren J, Garthwaite K, Bambra C. Rethinking the Work Capability Assessment. London: Demos, 2015.
8    Mirza-Davies J, Brown J. Key statistics on people with disabilities in employment. House Commons Libr Brief Pap 2016; 7540.
9    Burstrom B, Nylen L, Clayton S, Whitehead M. How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework. Disabil Rehabil 2011; 33: 453–66.
10    Clayton S, Bambra C, Gosling R, Povall S, Misso K, Whitehead M. Assembling the evidence jigsaw: insights from a systematic review of UK studies of individual-focused return to work initiatives for disabled and long-term ill people. BMC Public Health 2011; 11: 170.
11    Cooper K, Stewart K. Does money in adulthood affect adult outcomes? York: Joseph Rowntree Foundation, 2015 (accessed July 30, 2015).
12    Barr B, Kinderman P, Whitehead M. Trends in mental health inequalities in England during a period of recession, austerity and welfare reform 2004 to 2013. Soc Sci Med 2015; 147: 324–31.
13    Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Community Health 2015; : jech-2015-206209.

By Professor Azeem Majeed, Head of the Department of Primary Care and Public Health, Imperial College London

The departure of the UK from the European Union (EU) will have wide-ranging consequences for public health. The UK first became a member of the EU in 1973 and as a member of the EU for over 40 years, the UK has played a full part in European-wide public health initiatives. These have covered many areas, including food regulations, road safety, air pollution, tobacco control and chemical hazards.

Cross-national approaches to public health are essential when dealing with issues that do not stop at a country’s borders (eg. air pollution) and when dealing with large, multi-national corporations over which any single country will have only limited influence. Although EU public health initiatives have had important positive effects on health in the UK, there will be strong resistance from pro-Brexit politicians in participating in future programmes, as they generally view them as unnecessary interference in the UK’s internal affairs. The UK will also find that it is no longer able to lead such programmes or have much influence over their content, which will inevitably damage the leading role that the UK has played in public health globally.

The NHS will also find itself facing major challenges because of Brexit. With over one million employees and an annual spend of over £100 billion, the NHS is England’s largest employer. For many decades, the NHS has faced shortages in its clinical workforce and has relied heavily on overseas trained doctors, nurses and other health professionals to fill these gaps. This reliance on overseas-trained staff will not end in the foreseeable future. For example, although the Secretary of State for Health, Jeremy Hunt, has announced that the government will support the creation of an additional 1,500 medical student places in England’s medical schools, it will be more than 10 years before the first of these extra medical students complete their medical courses and their subsequent post-graduate medical training.

The recruitment of overseas-trained health professionals has been facilitated by EU-legislation on the mutual recognition of the training of health professionals. This means that health professionals trained in one EU country can work in another EU country without undergoing a period of additional training. For example a cardiologist or general practitioner trained in Germany would be eligible to take up a post in the NHS. Moving forward, it’s unclear that this cross-EU recognition of clinical training will continue. As inward migration to the UK looks to be the most politically contentious area in our post-Brexit future, we will need to take urgent action to ensure that the NHS has sufficient professional staff to provide health and social care for our increasingly ageing population.

The UK’s government will also have to address the issue of access to healthcare, both for EU nationals living in the UK and UK nationals living overseas in countries such as Spain. Currently, all these individuals are entitled to either free or low-cost healthcare. It’s unclear what will happen in the future, and this is particularly important for the UK nationals living overseas, many of whom are elderly and who will have a high level of need for healthcare. As the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.

In conclusion, Brexit will have important impacts on public health and health services, with scope for wide-ranging adverse consequences for health in the UK. It’s therefore essential that public health professionals engage with government to ameliorate these risks and also gain public support in areas such as the benefits of participation in EU-wide public health programmes and the continued recruitment of health professionals from the EU.

By Sarah Payne

I have the privilege to be a Health Education England (HEE) academic fellow this year, taking up my fellowship just as summer was throwing us an extra few weeks of warm weather to take forward into the Autumn. My first weeks were a blur of getting my feet under the table in my new home, the Nuffield Department of Primary Care Health Sciences at Oxford University, meeting new colleagues and setting out my plan for the year ahead. I was then straight off to a week-long intensive course to learn the art of changing people’s behaviours – courtesy of Susan Michie and colleagues at the University College London Centre for Behaviour Change. And what a week it was! Not only was it a great course but it was a great way to kick off my fellowship year, providing lots of inspiration and a ‘to-do list’ as long as my arm to get stuck into when I returned to the office.

Developing a suitable research project and securing research funding for it was one of the aims of my HEE academic fellowship, so I was thrilled when I found out I had been successful in securing an award, from the British Heart Foundation, to fund my proposed research project – investigating ways to help people with high blood pressure reduce their salt intake. Cue a short but wild celebration – short because the funding was contingent on having ethics approval for all elements of the research in place before the award would be given. So, duly inspired from my behaviour change course and brimming with enthusiasm to delve into the literature to understand more about the target behaviour I hoped to change and effective behaviour-change techniques to do so, and to spend some quality time developing a behaviourally informed intervention… I was faced with ETHICS FORMS! Hmmm….not so inspiring, though of course a critical part of the process.

Thankfully, the HEE fellowship provides a perfect bridge to support the development phase of my work, allowing me to prepare detailed research protocols and all the associated documents that support an ethics application for my proposed research and to begin some of the training in research skills needed to carry out the research. As well as fulfilling the immediate requirement to secure my longer term PhD funding, the process of preparing ethics applications has forced me to consider the finer details of my research and really think through how I will deliver it. I’ve had great support from my supervisors and my department – including the opportunity to gather valuable statistics feedback from the regular department Stats Coven!

So, a slightly different focus for my first six months than I had planned, but it has so far been a fulfilling and interesting time, as well as suitably productive. I’ve attended a couple of other short courses, both of which have helped to keep my ‘inspiration and enthusiasm’ barometer high. I’ve attended various department seminars and workshops and had an opportunity to meet and network with other PhD students. Naturally, I’ve also learnt the ins and outs of the various ethics processes and undertaken some training in research integrity and good clinical practice!

So onward and upwards. I have submitted my ethics applications and I’m in the midst of the lengthy process of amendments and waiting… and waiting… Perhaps I will use some of this time to explore that behaviour change literature-base I’ve been waiting to get to. Maybe there are even the beginnings of a systematic review in sight…

Sarah Payne is a Health Education England Academic Fellow

claire-beynon-at-fph-conference-2016My name’s Claire Beynon and I’m a registrar in my third year of training.

I went to the Faculty of Public Health (FPH) conference in Brighton last year (above) and I’m going to this year’s event in Telford in June.  So I thought I’d offer some thoughts on the benefits to other registrars of coming along as well.

As a registrar working in Wales I know most of the people in my area really well, but I don’t have much of a chance to find out about what’s happening across other parts of the UK or meet other registrars.

The FPH conference brings registrars from across the UK together.  Last year I met several other registrars from opposite ends of the country and we shared stories and experiences about the different health systems we now work in.

I also bumped into a few people who I hadn’t seen in a long time, and we caught up in the relaxed breaks and mealtimes over the course of the two days.

I was lucky enough to have my abstract accepted last year and I spoke in one of the parallel sessions on childhood obesity.  I shared my work with people who, like me, are really dedicated to tackling childhood obesity.  I found it was a great platform to share work you have finished recently and get some vital feedback and new ideas from other experts in the field.

The thing I liked most about last year’s conference was the atmosphere.  As we all know, people working in public health are fabulous, so perhaps it isn’t a surprise that the conference was fun.

The FPH Specialty Registrars Committee (who represent registrars) also has a dedicated conference session at which registrars will be sharing their experiences of the National Treasure placements.

And there will be time to socialise too.  This year committee members will all be at the conference party at the end of day one.  It’s going to be a fantastic opportunity to get to know people informally who you will very likely end up working with over the rest of your career.  So come along and say hello!

You can register to come to this year’s conference here http://www.fph.org.uk/fph_annual_conference_and_public_health_expo_2017

By Dr Nadeem Hasan

The importance of effective advocacy to achieving public health goals cannot be overstated.
Every day policies and regulations that affect health outcomes for better or worse are put on the agenda and kept off the agenda; discussed and debated; approved and rejected.

Many, if not most of these relate primarily to non-health sectors, such as food and beverages, energy and infrastructure, and alcohol and tobacco. But their impact on health outcomes is very real: all the stop-smoking programmes in the world can’t match the impact of the ban on advertising and smoking in public places on smoking prevalence; and there’s no amount of spending on childhood obesity programmes that can make up for the regulatory vacuum in this area.

Looking more broadly, policy decisions that affect income inequality, carbon emissions, and military action all have serious consequences for health across the world.

If we’re serious about prevention, we need to be serious about advocacy.
Where profits can be affected (almost everywhere), industry lobbyists seek to influence the regulatory environment in their favour. And they are very good at it. In principle, this is quite right – those affected by policy and regulatory shifts should indeed be able to make representations and provide additional evidence to support the decision-making process – and this includes relevant industry actors.
Representing the interests of everybody else is where advocacy organisations come in – acting as sort of ‘civil society lobbyists’ to balance out the discussion – advocating on behalf of the health, wellbeing, and broader concerns of the general population. Notably, this isn’t always an ‘us vs. them’ relationship: health insurance companies are routinely allies on advocating for lower drug prices; and renewable energy companies are more than happy to work with advocacy organisations on climate change regulation.

Put this way, it might sound like a fair playing field, with decision-makers receiving submissions from a range of groups and making balanced decisions to maximise the benefits to all parties. The reality of course is quite different, and much, much messier.
In 2014, there were an estimated 30,000 industry lobbyists in Brussels alone, falling just short of the 31,000 employees for the whole European Commission.

Civil society pockets are not deep enough to come close to matching this (or the salaries of lobbyists), and civil society advocacy and pressure groups are few and far between. Transparency falls short of the ideal, and the revolving door between policy-making and industry remains alive and well. Most recently the former President of the European Commission José Manuel Barroso was appointed Chairman of Goldman Sachs International, a move that has been widely criticised.
Advocacy organisations, then, have a difficult task – but one where even small successes can have far-reaching benefits for public health.
The European Public Health Alliance (EPHA), based in Brussels, is one such advocacy organisation. They bring together a range of health-related NGOs to advocate for better public health in Europe, working across five campaign areas: antimicrobial resistance; food, drink and agriculture; healthy economic policy; universal access and affordable medicines; and trade for health (and specifically the EU-US free trade agreement – TTIP – and the EU-Canada free trade agreement – CETA). Earlier this year, they hosted myself and another registrar in a pilot placement to understand health advocacy at the European level and to develop skills in this area.
So how to sum up the placement?
Invaluable. EPHA track the policy process for each one of their campaign areas and engage at every possible point. They attend every meeting at the European Parliament and the European Commission on these areas and make oral contributions at every opportunity; they submit comprehensive written responses to every relevant consultation; they engage on a daily basis with journalists to publicise their positions and build public support; they engage like-minded actors in the public, private, and not-for-profit sectors on a case-by-case basis to coordinate action; and they do all of this with just a handful of relatively young staff and interns.

They were very welcoming in bringing us into the whole process, allowing me to engage in every one of these steps – from writing position papers and consultation responses to making oral contributions at the European Commission and Parliament on their behalf.
Notably, EPHA also position themselves as an advocacy agency that actors from across the spectrum can engage with – in contrast to, for example, much more vocal organisations such as Greenpeace.

By way of example, the area that I was working on was TTIP. Whilst there are a raft of advocacy organisations across Europe (and the USA) that reject TTIP outright, EPHA’s

approach is to work through the whole agreement and advocate for the protection of public health on a section-by-section basis without rejecting the whole deal. With the European Commission politically committed to getting a deal, this makes EPHA one of the few organisations they can meaningfully engage with on this issue (though recent developments have called into question the likelihood of getting a deal in the near future).

This isn’t to say that their approach is ‘superior’ – every actor plays a particular role, with the more intransigent organisations key in shifting public opinion and providing the space for actors such as EPHA to engage in more balanced discussions. This means that they are invited to closed-door sessions with only a handful of actors, and have much more influence on the process than they otherwise would.
One of the challenges from a ‘public health professional’ perspective was that effective advocacy sometimes involves taking – shall we say – a less balanced view than we would normally as technical experts. From an ethical perspective, this raises a number of questions around whether the ends justify the means. I witnessed first-hand industry lobbyists making quite outrageous claims, including a rather undignified moment where I coughed up half my glass of water in a large auditorium at the European Commission when it was submitted that ‘alcohol is in no way an unhealthy commodity’ .

In a world where climate change denial is alive and well despite the most overwhelming evidence to the contrary, the ‘best’ approach to making our points is perhaps not so easy to discern.
And what of the relevance to the UK, particularly as we now start closing our doors to the EU in a bid to be a more open, global-facing country?
Whether or not the UK is a member, the EU remains a powerful actor that can influence policies related to public health both for its own citizens (which will still number ~450m after the UK leaves), and globally. As a close neighbour, EU regulations will have a strong bearing on public health in the UK too, and so engaging in advocacy at this level will continue to be an effective approach to improving UK public health.

This is true for everything from environmental regulations and air pollution, to pharmaceutical regulations and drug pricing and safety.
Within the UK, whilst it’s true that our policy-making process is not as amenable to advocacy as at the EU level (or remotely as civilised), effective advocacy still has huge potential to improve public health. We have not done well recently, with a watered-down childhood obesity strategy, no resistance to an unfunded ‘7-day’ NHS (that differs from the 7-day NHS that has existed since 1948 in some undefined way), and year-on-year increases in the use of food banks without any policy response (to name just three areas).

At the local level, there are a cornucopia of opportunities for advocacy to improve health, from influencing urban planning (fast food outlets close to schools, street design, cycling lanes) to advocacy around shifting public perceptions e.g. from opposing to welcoming refugees into local communities.
In this context, strengthening the advocacy skills of the UK public health workforce through engaging with and learning from experienced actors such as EPHA should be pursued with vigour – we can ill afford the alternative.

Dr Nadeem Hasan is a Specialty Registrar in Public Health