Archive for October, 2013

by Ralph Smith, Deputy Head of Public Health Information, Public Health, Sandwell Metropolitan Borough Council

The future of some vital public health-related information hangs in the balance as a result of the ONS Consultation on Statistical Products 2013.  The bland title of the consultation belies the rich and varied statistical products it covers.  They are divided into four areas, with the last two representing the bulk of the products in question:

•    Output from national surveys, such as the general lifestyle survey
•    Regional and local outputs
•    Health statistics and analysis, life events
•    Health inequalities analysis

Respondents are asked to state what the impact would be of discontinuing the product and encouraged to expand on the consequences if an impact is anticipated.

There are some critical products on the list and I encourage public health professionals to take part in protecting them.  Increasingly, policy documents are emphasising the importance of robust data sources and analysis, so it is an unfortunate time for ONS to be proposing cuts.

We are all going through a period where the provision of local public health analysis is under pressure due to a shortage of skilled staff, increased demand in a Local Authority environment and problematic relationships with the NHS over access to data.  At the same time we are reliant on national organisations, such as ONS and Public Health England, to provide nationwide data produced through economies of scale.

The consultation document often refers to alternative sources of data to the one they are suggesting they may cut.  But what happens if that alternative source dries up too?

One proposed product to discontinue is the monthly reporting of death registrations.  The monitoring of excess winter mortality relies on such data sources, both nationally and locally.  Indeed Local Authority Public Health has its own supply of mortality data, via the primary care mortality database.  What the national monthly data provides are vital comparators to help make informed analytical decisions in areas such as health and housing.


Figure 1: monthly death and mean monthly temperature, Winter 2012/13 for Sandwell

Winters may be getting warmer on average, but cold snaps are happening later in the season.  Thus, austere conditions that influence a household’s ability to heat their home means that such health and housing topics are still very much on the agenda.
In the health inequalities section of the consultation, many of the products are vital to public health.  They act as either a national benchmark to monitor progress, or provide small area analysis for local authority public health to reduce inequalities within their boundaries.  Life expectancy and healthy life expectancy analyses were first commissioned from the Marmot secretariat.  This small area intelligence was used to draw attention to the spread of health inequalities within an area, helping to target scarce resources.  A refreshed update of these data is under threat.

ImageFigure 2: Life expectancy and disability-free life expectancy at birth, by neighbourhood income level, England and Sandwell 1999- 2003

There are several products that take a closer look at health outcomes by protected equality groups such as occupation, deprivation and gender. Often there are no alternatives to such analyses.

Discontinuing the products outlined in this consultation does not only affect the professional public health world.  The idea of using freely available datasets and presenting them simply and clearly is increasingly popular with the media, charities and the voluntary sector.  The Guardian Datablog frequently uses ONS data to drive home a story.

Coupled with novel ways of presenting information, this brand of data journalism creates debate on current social issues.  And it’s not only the broadsheets that use this method.  The free paper the Metro frequently uses public domain national data to producer infographics such as the one below.

ONS are not looking to discontinue all the products listed in the consultation.  However they are looking for users to help them prioritise statistical products, some of which have to be cut to help contribute to annual savings of around £9 million.  I encourage you to take part in the consultation and emphasise how important  the majority of the products are in influencing policy and informing interventions.

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  • by Lucy Smith

Public Health Manager – Mental Wellbeing
Lambeth & Southwark Public Health Directorate
London Borough of Southwark

Public health work in Lambeth and Southwark has always sought to include a programme improving mental wellbeing for all who live and work in the borough. This includes improving mental health literacy, increasing capacity in the community and workforce to do more to understand and work to promote and protect mental health and to influence policy and strategy across all areas.  Brixton Reel is an outreach project as part of the wider programme.

Lambeth and Southwark have high levels of mental ill health with around 30-53,000 people aged 16-74 years old who could be suffering from common mental health issues such as anxiety and depression. In addition there are groups who do not have a diagnosable mental disorder but who score low on life satisfaction and wellbeing scales, such as people who have a disability, are unemployed or carers or in receipt of benefits.

Lambeth & Southwark have an ethnically diverse population with a large black and minority ethnic community, mostly black Caribbean or black African. There is also a large white Portuguese speaking population in Lambeth. In Southwark there is a Latin American community of mainly Spanish speakers.

The Brixton Reel Film Festival was first commissioned in 2009 by Public Health to promote positive mental health and wellbeing in African/African Caribbean communities and to help empower those communities to take action to take care of their own wellbeing.

It also seeks to use film as a medium to de-stigmatise the concept of mental health, promote and improve recovery and accessibility of services, such as local psychological therapies and to understand more about the experience of living in the borough for different communities.

The project is delivered in partnership with a range of partners (often smaller organisations) such as Telefono de la Esperanza, Amardeep and Carenet who provided outreach, staff time and venue space. It is thanks to the support of partners and match funding from the Maudsley Charity that the festival has grown and successfully reached its target communities .

In 2012 the festival expanded to include an event in Peckham for the first time. Six film events were held at local cinemas and community hubs with free food and entertainment and open to all. Representatives from the health community and volunteers engaged in talking to people about mental wellbeing.

‘Sing your Song’, about the life of the African-American singer and human rights activist, Harry Belafonte, was one film screened. A lively and informative panel discussion took place afterwards with social activists, historians and actors about how Harry’s life story exemplified the ‘five ways to wellbeing’.

A final event was held in March at a Portuguese restaurant with Fado singers. A previous festival included the screening of a short film, ‘Connect’ made by young people from St Martin’s Estate, Tulse Hill, who then had an opportunity to engage in a Q & A session and meet actors from the film ‘Attack the Block’. Other events included laughter yoga and bollywood dancing as well as short film to promote the link between physical activity and wellbeing.

Evaluation of last year’s festival recorded almost 800 people attending. Of those who completed evaluation forms (284), 84% said the events had increased their understanding of mental health and wellbeing, 65% had found out information about services that could help them, friends or family. Over two thirds (63%) said it had changed their view of people with mental health issues.

A fifth of the audience were White or White British with the majority being from target groups of black British/Caribbean or African background and 6% Asian. There was a cross cultural aspect to the festival with events being attended by African-Caribbean and Asian communities who may not socialize together in other circumstances.  The festival also had radio coverage in the form of live debates on Colourful Radio and BBC Radio London’s Sunny and Shay Show.

Brixton Reel 2013 is funded by Lambeth CCG and London Borough of Southwark and  will take place this November. For more information on this project or full evaluation report please email: lucy.smith@southwark.gov.uk

Feedback about Brixton Reel:

“I’ve just moved to Brixton and it is really nice to know there are fun, free and interesting events on here. It’s good to know that mental health is taken seriously too”

“Such events are very important because being “alone” (at home) is a feature of poor mental health. Bringing people together often (in small ways) is needed”

“This event is important to allow friends to express how they are feeling after the event, touch on subjects that might have been not spoken about, which leads to better understanding.”

‘Participating in the activities and speaking with the public about mental health. Also I found quite satisfying was when I encouraged an individual to speak to another organisation relevant to their needs’ (Festival Volunteer)

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by Martin McKee
Professor of European Public Health
London School of Hygiene and Tropical Medicine

Anyone walking through London’s King’s Cross station this week could be forgiven for thinking they had been transported mysteriously to somewhere else. Not, in this case, on the well trodden (albeit fictional) path by way of platform 9¾ on the Hogwart’s Express but rather to an earlier time, when cigarette advertisements were still legal. All along the stairways are pictures of what seemed to be cigarettes set against a soothing, healthy-looking blue background yet when you got up close you realised that they were actually Nicolites. The mistake is easily made. Indeed, the manufacturers take pride in the fact that their products are “designed to look and feel like real cigarettes”, which they certainly do.

As one branding expert said about an advertisement for E-lites, a competing brand, “everything about the ad and the way it’s targeted and it’s marketed to people does appear to be just like cigarettes”.  With both products, the white barrel containing the battery looks just like the tobacco containing part of a cigarette, complete with a LED at the end that lights up when the user inhales. The nicotine container looks just like a filter tip. The marketing strategy is clearly working. Nicolites’ manufacturers advertise it as “the UK’s favourite electronic cigarette”, a claim seemingly borne out by independent sales data showing that their various brands account for six of the top selling brands of e-cigarettes sold in independent shops.

Yet e-cigarettes didn’t always look like the real thing. The early ones were quite different. Mechanical devices looking like something you might find under the bonnet of a car, with names that reflected their strange design, such as sonic screwdrivers, named after the instruments used by Dr Who. There was no risk that anyone would confuse them with a real cigarette. And just like Dr Who, these strange devices have attracted a remarkably dedicated group of supporters, as I discovered recently when I wrote a BMJ article on e-cigarettes. The article came about following the 2013 WHO European Regional Committee, where ministers from many of the smaller European countries were discussing the advertising blitz they were experiencing from the manufacturers of e-cigarettes (the ones looking like the real thing).

I did some homework and it rapidly became clear that the tactics used to market these so-called cig-a-likes were exactly the same as those used by the tobacco industry. These featured prominently highly sexualised advertisements and references to celebrity users, such as Katy Perry, Leonardo DiCaprio, Kate Moss and Lindsay Lohan. The e-cigarettes often contained flavours known to attract children, whether in cigarettes or alcopops, such as bubble gum. I heard from colleagues in several countries of new outlets springing up outside schools.

In my paper, I recognised that, just like any nicotine delivery device, e-cigarettes could play a role in helping people quit, although as most quitters succeed unaided, it is likely to be quite minimal, and anyway, the latest evidence from a New Zealand randomised controlled trial showed that they were no more effective than patches. But that wasn’t the point. The real issue was the way that these products, “designed to look and feel like real cigarettes” offered a means to get round advertising bans and to counteract one of the most effective measures against smoking, the campaign to denormalise it.

This had been so successful that those celebrities who did smoke would conceal it. Yet, as was already becoming clear, some were willing to be seen vaping, the term used to describe using e-cigarettes. And of course, e-cigarettes, if allowed to be used in public spaces, would undermine the remarkable success of smoking bans that have been policed by popular consent as bar staff would have to constantly check whether what someone was using was the real thing or an electronic copy.

I didn’t call for them to be banned. I simply called for them to be regulated just like other nicotine delivery devices and for advertising to be banned. In the light of what I have subsequently learned, I would add three more requirements. First, no company (including subsidiaries) should be able to manufacture both e-cigarettes and real ones. Second, they should not be designed to look like the real thing. And third, they should not be allowed to be used anywhere smoking is banned.

The response to my paper was remarkable. Within an hour of it being posted on the BMJ website I was the subject of dozens of messages on twitter. Most portrayed me as an idiot, but a significant minority believed I was evil (or both, calling me a “vile cretin”). I had absolutely no idea of the ability of those promoting e-cigarettes to mobilise so quickly and effectively!

So what had I done to upset them? Well, the main criticism was that the e-cigarettes I, and my colleagues at the WHO meeting were seeing advertised everywhere were not real e-cigarettes. Those attacking me sent dozens of pictures of the metallic contraptions they used, none of which looked anything like a cigarette. Indeed, the abiding impression is of what one might see if anyone ever created a museum of spark plugs. They also sent testimonies of how e-cigarettes had helped them cut down or quit smoking. Leaving aside the abusive tone of most of the messages, I was perfectly willing to accept what they said. They obviously did use these devices and I am sure that some of them found that they helped them to quit, even though I was equally sure that there were many more people who had quit without them.

When faced with such sustained criticism, it is important to reflect on whether you might be wrong. I put the term “e-cigarettes” into Google Images and, lo and behold, the vast majority of pictures were just like the ones I had seen advertised. There were a few of the mechanical devices, but only a very few. Then, some of my Twitter followers helpfully send me pictures of e-cigarettes being advertised in other countries. They also looked like the real thing. In some of the pictures, however, you did have to look hard as they were placed just beside the candy shelves, exactly where you would expect a kid to look.

The tide of abuse continued for several days. These things happen when you stand up for public health. But then something strange happened. Someone created a web page with a picture of me, subtly changed with reds, yellows and pseudo Cyrillic font, to look like a Soviet leader. They warned that I was “eliciting howls of rage from the vaping community, McKee is attempting to show vapers in the poorest possible light. Thuggish neanderthals who lack the wit, intelligence and willpower to abandon their filthy addiction to nicotine. Foul-mouthed fake smokers who will launch personal attacks upon a widely respected public health professional. It’s crude, but it can also be effective.” It was as if I had laid a trap into which they had fallen. If only I was so clever!

They accused me of a fundamental disdain for harm reduction, a strange argument as I chair the Global Health Advisory Committee of the Open Societies Foundations, the leading global funder of harm reduction in the drugs field. The attacks subsided for a while, but soon recovered, following the publication of a letter in the Daily Telegraph signed by the leading UK organisations working for tobacco control, including FPH, ASH, the RCP, Cancer Research UK and many others, as well as a large number of individuals, me included. The letter showed a clear consensus in favour of regulating e-cigarettes as a medicine and banning their advertising, the position I had advocated in the BMJ and which is supported by the UK government.

So what do I conclude from this experience? There is clearly a dedicated, highly vocal community using devices that look nothing like cigarettes. Many of them are, doubtless, deeply committed to harm reduction, but I argue that they miss the much bigger picture. However, given what we know about the tobacco industry, now that it has jumped on the e-cigarette bandwagon, it would be foolish to ignore the possibility that some of those responding with such speed and intensity to any challenge to e-cigarettes represent industry-manufactured Astroturf rather than spontaneously emerging grassroots.

Second, there are many small-scale manufacturers of these devices, some of whom almost certainly came into the business because they want to help people quit, although others probably saw the opportunity to turn a quick profit. But, with all due respect to these groups (even if it is not reciprocated), they are essentially irrelevant in the greater scheme of things. Big Tobacco once saw e-cigarettes as a trivial issue, given the work they had done to perfect the real thing as a product designed to attract kids. However, in the past year that has changed completely. It has spotted the new opportunities to circumvent advertising bans, via brand stretching and ambiguous imagery, and to renormalize actions that look for all the world like smoking.

Altria, the owner of Philip Morris USA, has just launched its first e-cigarette, MarkTen, using a subsidiary company. R.J. Reynolds has launched its new e-cigarette, Vuse. Lorillard acquired Blu Ecigs, one of the market leaders in the US and is expanding outlets rapidly. The small companies that initiated the manufacture of e-cigarettes will be swallowed up, as in every other field of commerce, and e-cigarettes will simply be a marketing extension of the real thing.

Unfortunately, some of the most vocal supporters of e-cigarettes seem oblivious to this development, with Clive Bates contending that “The normal controls on truth and fairness in advertising, supplemented by restrictions of the type applied to alcohol, should be sufficient to balance public health opportunities and fears that something might go wrong.”  Those working in the alcohol field might consider this rather at odds with their experience.

Simon Chapman, perhaps the leading tobacco control advocate worldwide, has argued that “The indecent rush to facilitate the growth of ecigarettes may prove to be one of this century’s most myopic and catastrophic public health blunders.” He continues “I so hope I am wrong.” Sadly, I fear that he won’t be.

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By Dr Mary Black,  Director of Public Health for the London Borough of Havering

I am a new Director of Public Health reporting directly to a Council Chief Executive. I have a seat on the senior management team and picked my local authority largely because of that. The public health team has been warmly welcomed; we even had a special ceremony arranged by the mayor to welcome public health home to the local authority (admittedly my idea but enthusiastically received).

A senior management retreat was held to cement my partnership with the Chief Executive and other Directors. At no stage have I felt ignored or less than appreciated.

It is confusing at times in this weird and wonderful new world. I am impressed with the competence of the foot soldiers on all sides that have now implemented these latest NHS reforms, in other countries restructuring on this scale would likely have simply failed. Occasionally I rather wish they had been less competent and let the restructuring all grind to a halt.

On a good day it feels as if the cobwebs have been blown away, public health is in its right place, and finally we get the chance to strut our stuff in the real world. On a bad day it feels as though we are all marooned on the rapidly separating ice floes of our respective organisations, and unfortunately we are heading south.

It is a huge shame that all Directors of Public Health (DsPh) are not at the top management table in our local authorities. Those of us who are will need to demonstrate pretty fast that we deserve those seats and in some places we may well struggle to keep them. We have another 18 months, perhaps less, to prove our value.

For this we will need useful and well skilled public health specialists who can help lead and manage local authorities through a time of unprecedented cuts, take on the challenge of shared health and social care, and be pragmatic crusaders for the use of evidence. We need future leaders who can get off their soapboxes and roll their sleeves up.

The recent decision of Lancashire not to appoint a Directors of Public Health to the top table has sent the Faculty airwaves chattering. It is worrying that our hard won public health specialty tickets may not be valid in future. But my question is this – has the Faculty foreseen and adjusted to the new world and is it now churning out the kind of public health leaders we will need in future?

I recently signed off on a full restructure and now the scanty team I inherited can expand to full strength. I have had no problem arguing that my two new consultant recruitments will be on NHS terms and conditions. I am wondering, though, if I can find the people that I need to take on these jobs.

I take it as given that consultant applicants will be highly literate and numerate, have excellent technical knowledge, be able to knock out a needs assessment, and know their way around health inequalities. Will I be able to find someone who can work out the machinations in the acute sector, position evidence in the right place at the right time in the commissioning process to actually make a difference, and explain a public health concern in the kind of jargon-free language that an average councilor can actually understand?

Will I find a partner in crime to help me write an annual report that people actually read and use and that makes a difference? Can I find someone who can peddle influence in messy situations, horse trade with tiny budgets, get GPs to change their ways and understand how to write and performance manage a contract?

Will I find a diplomat who can infiltrate the council with public health thinking without alienating colleagues in other Directorates – colleagues who would love to be able to plan 20 years ahead while implementing creative pilot projects, but who are actually watching their core budgets being slashed to ribbons and are worried about the safety of some of very vulnerable people in their care? Can I find someone who can rewrite the rulebook with the same passion and nouse that led to the NHS being set up in the first place?

Reverting to my analogy in paragraph four: I am sitting on my ice floe, paddling like hell as I know what will happen if I do drift further south. I have formed an alliance with the hungry polar bear from another post April 1st organization (pick from the long list) that has just swum alongside. The bear did look a bit scary, but my expertly tossed piece of salmon has converted him into a firm ally on the assurance/crisis/partnership board coordinating … (pick from the long list of technical areas). Life is exciting if somewhat complicated.

Which brings me back to my recruitment pitch: “Actively seeking numerate, faculty-endorsed public health enthusiasts. Must have a sense of humour, a killer aim for throwing a well targeted fish, and a big enough vision to understand that we really must tackle global warming or we are all going to drown.”

Any takers?

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