Better Health For All

In public health we often work in partnership with statutory and non-statutory organisations developing relationships that are necessary to implement public health projects to benefit local communities.  How often have we teamed up with colleagues where the relationship is informal, not prescribed and not expected?

April 2020 the national spotlight was on acute physical health care and there was a frantic attempt to scale up provision of acute beds and ventilators. Those of us working in community Trusts saw our services take a back seat and many were stopped altogether; but there was unease over impending problems over the horizon. What would be the impact on community rehabilitation services? What would the mental health ramifications of the pandemic be?  Would our community palliative care services cope?  

It was reassuring to network with other public health colleagues who had similar concerns. Connected by the national network for public health professionals working in providers (facilitated by PHE) we joined forces and worked as one team on this topic of mutual concern. One of the challenges for public health specialists in provider trusts is that we often work single-handedly and don’t have colleagues in a team, as in local authorities for example. Becoming a virtual team (consultants, StRs) doubled the number of people working on the project and meant we could split up article reading and writing up. It also gave us more brains to think about the implications and critique what we were reading and thinking. We barely knew each other, but had our training in common and shared public health language meant that we were able to work effectively together – and enjoyably!

So even before the term Long Covid had been coined and mental health concerns had been profiled nationally, we had teamed up and started needs assessments and were doing papers for our local integrated care systems. We even managed to submit articles for publication. 

Furthermore, we have continued regular problem solving meetings and act as a virtual department separated by a dotted line of a few hundred miles. Freed up from formal, standard ways of working – under the radar – our organisations get a greater range of public health expertise than they pay for!

Jane Beenstock
Consultant in Public Health

Dr Zafar Iqbal
Associate Medical Director Public Health
Chair, FPH Pakistan SIG

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Given the widespread recognition of COVID-19 as a public mental health emergency that has deepened existing mental health inequalities, the theme set by the World Federation for Mental Health for World Mental Health Day on Sunday 10^th October – Mental Health in an Unequal World – was especially fitting.

It seemed to have come around even more quickly again this time, which probably says a lot about what the past year has been like. Those of us working in public health will be well versed in efforts to promote wellbeing in our own organisations and others, particularly at a time when workload and stress have been high and morale has been low.

What comes through less clearly is where the focus is not just on reducing stress in individuals, but on tackling wider underlying issues contributing to that stress – particularly where there are marked disparities.

I don’t just mean equal access to support, services and activities that help to improve wellbeing, although that is extremely important – both in our own workforces and the populations we serve. I’m talking about workplace policies, working practices and cultures that seek to actively counteract prejudice, discrimination and structural disadvantage, all of which are detrimental to mental health and wellbeing.

In other words: what are we doing to advance equality in our own workforce?

Last year the FPH highlighted the importance of embedding anti-racism into public health practice. This means challenging our own unconscious biases and refusing to be silent bystanders to racism in our own organisations. The same principles can be applied for other forms of discrimination, including but not limited to sexism, ableism and homophobia – however, this is as much about questioning the status quo in the ways we work as it is about challenging overtly discriminatory behaviour.

The public health workforce is diverse in itself (people, roles, organisations) and has wide-reaching links across partner organisations and communities. If we want to be effective advocates for mental health equality in the population, we need to start with equality overall and we need to start from within.

What stress means and what it looks like is different for everyone, but can be summarised as ‘a lack of fit between individuals and their world’ (Cassidy, 2001).[1] We’ve started to recognise the limitations of traditional workplace wellbeing approaches, which focus on supporting individuals to fit into existing structures rather than improving their ‘world’ to fit them – but we also need to be looking at who built that world in the first place. Many workplace policies and interventions for inclusion and wellbeing still operate within norms and cultures that have been established by white, middle class men without disabilities – even where workforces are considerably more diverse, and even where there is representation at senior levels.

For example, offering flexible working arrangements such as flexible start/finish times and remote working can improve work-life balance and wellbeing for people with children or care responsibilities (who are disproportionately women), or those with disabilities or long-term health conditions. Yet limiting the offer to these groups where there is no real business need to do so just reinforces the current culture as the norm and those who don’t fit in as ‘others’, instead of including everyone as equal partners in re-shaping that culture.

It also ignores the wellbeing benefits that these changes can have for everyone. A workplace that promotes equality and diversity is a workplace where everyone can flourish and feel that their contribution is valued. More flexible working as standard can help to improve work-life balance for all. Making workplaces more autism friendly can make those workplaces happier, calmer and more productive spaces for everyone. When we default to the status quo and consult rather than co-produce, we all miss out.

The brilliant Dr Nisreen Alwan explains this far better than I ever could in the context of language and anti-racism:

“Diversity” and “inclusion” imply charity from a position of power and superiority.

They give the impression that the group who is opening the door to diversify and include others still holds the key. The point of antiracism is that there should not be a key in the first place. The door should be widely open to all. Clubs with locked doors should not exist in an equitable society. Once that is achieved, the natural result of equity is diversity. It is the end not the means.”

So what does this mean for promoting mental health equality?

We cannot improve mental health and wellbeing in the public health workforce without actively tackling inequities in our workplaces – and we cannot address those inequities without confronting the structures underpinning them. Whether it’s improving opportunities and experiences of people with mental health problems, or reducing disparities in mental health and wellbeing, we have to actively change working practices that allow systemic discrimination to persist.

It isn’t enough to work to improve mental health in an unequal world; we also have to work to make the world more equitable to improve mental health.

Lina Martino

Chair, FPH Public Mental Health SIG

[1] Cassidy T (2001). Stress, Cognition and Health. Psychology Press: Hove & NY.

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A public health approach in policing allows opportunities to address the clear yet complex links between health, wellbeing, offending and behaviours which lead to contact with police. Social determinants of health, such as housing, education, employment and income, often mirror or overlap with social determinants of crime. Inequalities which result in poorer health and reduced life expectancy also result in increased likelihood of entering the criminal justice system or being policed for problem behaviours. Those at risk of offending are more likely to suffer from multiple and complex health issues, including mental and physical health problems, learning difficulties, and substance misuse.

In 2018 the national Policing, Health and Social Care consensus statement was published to set out how the police service and health and social care services would work together to improve people’s health and wellbeing, reduce crime and protect the most vulnerable people in England and Wales. In the run up to the publication of this document and in the years following public health and policing organisations have been working together, alongside other partners, to focus on prevention and early intervention, recognising that the majority of police work is rooted in complex social need. The Public Health and Policing Consensus Task Force was established to bring together these partner organisations.

The Landscape Review 2021 was published on 22 September which outlines the progress in leadership, practice, culture and evidence within policing since the publication of the consensus statement in 2018. This review describes progress and opportunities for development in four key areas:

• policy and systems
• evidence for primary prevention
• public health practice
• research in public health and policing

Policy and Systems

Since the formation of the Public Health and Policing Consensus Task Force there have been several policy documents related to public health approaches within policing. In 2019 a discussion paper was published considering what a public health approach in policing looked like. This described five key pillars for public health in policing: working at a population level, using data and evidence, considering the causes of the causes, prioritising prevention and partnership working. This paper has stimulated discussion within the policing community, ultimately resulting in the College of Policing and National Police Chiefs Council outlining the 5 key pillars as shared principles in a policy document. This and other documents explored in the Landscape Review have fostered partnerships across England and there are opportunities to build on this moving forward.

Evidence for primary prevention

It will always be difficult to prove you prevented something from happening which makes gathering evidence for primary prevention challenging. Primary prevention may also lie outside of traditional remits of an organisation (e.g. response to crime). However, for primary prevention to truly be effective all sectors must make it a priority. A mapping exercise was carried out as part of the Landscape Review which considered the evidence on the effectiveness of primary prevention in a public health and policing context. This found a lack of specific detail on “how” and “why” interventions impacted on outcomes.

Public health practice

A survey carried out by the College of Policing for the Landscape Review explored what progress has been made in embedding public health approaches in policing.  While there is evidence of effective partnership working and public health approaches more generally across a breadth of business areas within policing there is still more to do.

Research in public health and policing

Developments in policy, evidence and practice are promising, however, these must be realised in line with the evidence base. Therefore, a modified Delphi study was carried out across the four nations of the UK to identify priority topics for research as part of the Landscape Review. The results revealed a desire to prioritise wider social determinants of health and wellbeing, mental health and wellbeing, children and young people, vulnerable groups, and domestic and sexual violence and abuse in future policing and public health research.

The Public Health and Policing Consensus Task Force continue to forge and foster strong links between Public Health, Policing, Health and Voluntary Sector organisations with the ultimate aim of improving health and wellbeing of vulnerable people. If you would like to hear more about this area of work or to get involved with the work of the Public Health and Policing Consensus Task Force you can:

• read the Landscape Review 2021 here Public health landscape review published | College of Policing
• hear more from the Public Health and Policing consensus Task Force via Twitter (@police_health)
• Join our next webinar “A Public Health Approach to Modern Slavery” on 14^th October 2022 at 2pm https://event.on24.com/wcc/r/3420189/0F5F3C39E4C4F68B606B9DAB0333BCBF
• Future webinars will shine a spotlight on prevention and sports, trauma informed policing and law enforcement working with health colleagues around drug death prevention

Dr Jaimee Wylam
Public Health Registrar

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