Better Health For All

by Dr John Middleton, Vice President, Faculty of Public Health

One of my daughters gave me a copy of How to Be a Woman for Christmas. “Every man should read it”, so the blurb goes. Yet in these musings of a contemporary Black Country wench is evidence of just how much further there is to go for women to achieve equality, rights and health. It is not just the glass ceiling that aspiring women face that should exercise us, but the gross inequalities women face in global society.

Women are more likely to be poor and in low-paid, unskilled occupations. According to the Organisation for Economic Co-operation and Development and United Nations reports at the turn of the year, women perform 66% of the world’s work, produce half the food, earn 10% of the income and own 1% of the property. Women’s educational achievement will be at least as good as men’s but they are far less likely to have opportunities for advancement generation on generation, mother to daughter.

Over Christmas, “Victorian” has been much in evidence as a descriptor of UK public health – whether in relation to the rise in tuberculosis, the gin-factory fire in Sandwell, soup kitchens, rough sleepers and the undeserving poor. “Biblical” has been used to describe the unfolding horror and public health disaster of Syria. “Dark ages” has been used to describe the carnage of Newtown, the massacre of polio vaccination workers and the gang rape of Delhi.

In the field of crime it should be obvious that blaming the victim is unacceptable, and yet it goes on: the school didn’t protect itself; the rape victim was wrongly dressed. In public health the powerful and comfortable are renewing their assault on the victims of their health-destroying policies: John Redwood says the poor are to blame for the growth of betting shops; David Cameron praises the food-bank operators for their contribution to ‘Big Society’ rather than confess his shame for returning a civilised country to intolerable poverty.

In public health too we need to condemn victim-blaming and advocate for the health of the most vulnerable. Championing the health and rights of women and children in the early years is a key component of that.

The problem with the poor is poverty. The problems of violence and the problems of ill health are rooted in inequalities in opportunity and money between social groups, between geographical areas and between the sexes.

The North West Public Health Observatory in its tour-de-force report Protecting People, Promoting Health shows just what a massive public health problem violence is and gives us a public health approach to evidence to reducing it. It’s a Marmot report for violence-prevention and demonstrates how crucial early-years interventions and youth support are to reducing crime and violence.

But as well as its careful analysis of interventions which set the conditions for better health and positive, peaceful relations in communities, it also sets out a chapter on making behaviours which condone or encourage violence unacceptable. It is not women who are committing gang rape, it is not women who are off-loading barrel bombs from helicopters in Syria, and it is not women are gunning children down in US schools. But it is also not women who are determining the policies which are bringing about the impoverishment and bankruptcy of our nation and the next generation.

We in the public health community have been preoccupied with our own position in the NHS break up. I make no apology for that in the work of FPH – if we weren’t doing that no-one else was going to. But, as we look forward, it is time to look outwards, to re-establish our role as advocates for the health of the public. The health of the UK has not faced such a formidable threat for many years. The systematic impoverishment of the poorest, most disabled and most vulnerable is accelerating and will be given further thrusts in April and in October as the benefits cuts hit harder. Combining this with a fragmented and weakened health system, who will be there to hear the calls?

Educate a woman and you educate a village is as true for a UK housing estate family centre as it is for an African village.

And it’s as true for our national corporations, governments and institutions. As a new man fills another junior minister role, it appears there will be little new education in the Cabinet village.

In the new-year press, Professor Athene Donald continued her eloquent championing of the need for more girls to go into sciences. Looking for a happy new year for my daughters and granddaughters, and all our daughters and granddaughters, it is clear we need some fundamental power shifts. The public health specialty is well placed to demonstrate the greater involvement of women in all disciplines, and at the highest levels.

But in our advocacy for the public’s health, we must strive for greater equality for women, for the health of our national and the global village.

John Middleton, Vice President (Policy)

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Part Two: benefits of Health and Wellbeing Boards and risks to health protection

Dr John Middleton (pictured above), Vice-President of the UK Faculty of Public Health and director of public health for Sandwell in the West Midlands, gave evidence to the Communities and Local Government Committee on the role of Local Authorities in health issues on Wednesday 21 November 2012. This is the second part of two blogs based on an edited version of his evidence.

In moving into local authorities, [local authority staff] won’t know what they don’t know [about public health], and the need for the senior public health person to be at the chief officer’s table reporting to the chief executive is absolutely essential.  Directors of public health need standards, resources and powers.

One of the aspects of these reforms that worries me and some of my colleagues is the notion of assurance — that we will somehow float over the whole system and say it is all okay.  Is it a warm glow you feel when the hospital tells you it is doing the right thing, or is it a critical inspection of what is going on, be it in infection control, screening or any of the other areas?  Directors of public health need to have both the resource and the power to deliver those.

As to standards, councils are used to working in a peer-led environment with sector-led improvement.  The Faculty of Public Health is keen to support that process.  The whole system needs to work at a sufficient level.  If I as a local authority officer find that the neighbours are not doing as well as they need to on TB, genitourinary medicine or drug control, those problems are my problems too.  If I have a wonderful town planning service that does safe walking and cycling and those routes stop at the border, we will not get the best for public health, so we need standards across authorities.

I have … very little confidence in what I have heard described in relation to screening, immunisation and emergency planning around the NHS Commissioning Board.  The screening and immunisation staff we have trained and developed in Sandwell to work on a daily basis are destined for Public Health England. They will be seconded to the National Health Service Commissioning Board and managed by heads of public health commissioning with no qualification in public health, necessarily.  You would not invent that system were it not for the extraordinary difficulties that the health reforms put us in.

As to health protection, we need to emphasise that there is a whole preventive infrastructure in place in local authorities, but there has been a very successful infrastructure for infection control in primary care trusts.  The district infection prevention control officers have an excellent story of reducing healthcare-acquired infection.  These are not things where the Health Protection Agency historically has done a great deal of hands-on work. These are ecological problems.

If pharmacists prescribe loperamide, GPs prescribe antibiotics, care homes do not clean their mattresses more than once every 15 years and hospitals do not record the data on clostridium difficile, potentially these send infections spiralling around our communities, and we need to be able to see that preventive work carried on in local authorities.

All of the evidence suggests that mortality is strongly related to deprivation. The problem is that, when you look at what is in the ring-fenced budget, it is not about premature mortality; it is about genitourinary medicine services, school nursing and drugs and alcohol services.  We have used one formula potentially to describe a totally different set of problems and answers that we need.

If we simply reallocate the pot [of funding] we have, we will disadvantage those who have spent more against their level of need now.  As we have with health service allocations in the past, my understanding is that we using the formula to decide whether to move people.  There are other real problems with the ring-fenced budget not specific to the ring-fence: we are talking about an investment of £2.2 billion, and the risks around genitourinary (GU) medicine, which is growing by 3% or 4% a year.  For my PCT an extra £400,000 a year was nothing out of £500 million, but my local authority is extremely concerned about £400,000 out of £20 million.  This is an area of risk that local authorities are very concerned about.  In Westminster two-thirds of the budget goes on the GU medicine service, and they could spend all of the ring-fence in a very short space of time with those increases in activity.

Health and wellbeing boards are being embraced.  They have the benefit of having some continuity with the health and wellbeing boards that have been in place since 2007 in many cases.  They also have the benefit of being the least prescribed part of the Health and Social Care Act.  There is a lot of scope for local determination of what they look like.  They also have the benefit that they are the glue; they are the central point.  They are the only coherent part for many local authorities, and they are the engine room through which health strategy can be delivered.  It is a body we need to support and develop.

In Sandwell it is chaired by the leader of the council, and that top-level seriousness that is going into the health and wellbeing board is extremely crucial.  We have seen it at least as a meeting of commissioners; it is not yet a commissioning body, but we will need to pool more budgets potentially, not fewer.  We will certainly need to share our parallel investments in alcohol, drugs and so on, and it is a forum we want to support.

An additional positive is that that commissioning for drug and alcohol misuse, vulnerable young people and so on is coming into the local authority through public health. It is an opportunity to bring the safeguarding of children closer to a public health agenda.  In dealing with issues like domestic violence and new migrant populations there is a chance of a more co ordinated approach by local authorities, but the overall issue of eight separate commissioners is a problem.  The NHS Commissioning Board doing the nought to fives until 2015-16 suggests that we do not trust local authorities with that kind of commissioning, and that is a mistake.

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