Jim McManus is Executive Director of Public Health for Hertfordshire and President of the Association of Directors of Public Health.
Hertfordshire County Council recently approved its new Public Health Strategy (2022-2027), produced by multiple stakeholders including elected members. One of its main aims is to continue reducing the health inequalities existing in the county, which have been brought into sharp relief and worsened by the COVID-19 pandemic.
Our strategy recognises that Public Health has a major role to play in fulfilling the council’s corporate strategic priority – for our residents to lead healthy and fulfilling lives. We want to ensure we continue to develop and deliver a range of preventative services promoting health and wellbeing for all residents, particularly targeting people most in need. The strategy sets out the role of Public Health in getting there, and means citizens and partners know what they can expect of us.
This is important, because while the county’s health statistics are mostly favourable compared to national figures, there are persistent health inequalities, especially, but not only, in areas of deprivation. To take one example, we have historically significant and large Gypsy, Roma and Traveller populations across 55 sites. The work they are co-leading with us on suicide prevention, education and training and vaccination uptake will reduce inequalities.
The COVID-19 pandemic led to many more people experiencing inequalities through changed economic, employment or health circumstances. Several new health challenges have also arisen in Hertfordshire, including long Covid, an increase in mental health needs, more widespread harm from drugs and alcohol and increased numbers of overweight and obese adults and children.
The new strategy outlines our vision and priorities and highlights how, informed by best practice and evidence, we will work with colleagues, partners and communities to reduce health inequalities and support healthy lives for all.
A great example of how we are already doing this, is our Shape Up Together programme. Originally launched as Shape Up in 2015 to address inequalities in mens’ access to healthy living support – it was funded by Public Health, the Premier League and Hertfordshire’s district and borough councils, and run by Watford Football Club’s Community Sports and Education Trust. Delivered free, the programme aimed to improve the lives of men with a BMI of above 30 through bespoke programmes. Since its launch, over 1,000 people have collectively lost seven and half tonnes of weight and that’s just one outcome.
Although Shape Up continues to run, last year we identified a need to develop a programme aimed at some of our Black, Asian and Eastern European populations, people with a physical and/or learning disability and people with severe mental health issues. As a result, Shape Up Together was born. Although still in its early days, Shape Up Together (which is open to both women and men) is set to be as successful as its predecessor.
In May, we invited community and voluntary organisations to apply for grants of up to £10,000 each, funded by Public Health, to develop innovative community projects which responded to local needs and focused on promoting mental health wellbeing through physical activity.
With a specific remit to tackle inequalities by building resilience for residents with low to moderate mental health problems, the programme has awarded just over £100,000 to 15 local organisations. Successful projects included some very creative ideas, from dancing and Nordic walking to horticultural gardening and wild play. We are working on strong pathways between these projects and Money Advice services to reduce financial inequalities too.
Equitable digital inclusion is a corporate priority for us, but lack of availability of online access must not disproportionately exclude lower-income areas. We are using Togetherall, an evidence-based, clinically-moderated, online 24/7 peer-to-peer mental health community, for residents aged 16+ who are feeling low or depressed. It can help prevent mental health unwellness with support and courses, plus the additional benefit of professionals monitoring for signs of distress. This is just one tool in our kit of mental health support, ensuring those disadvantaged by limited access to other services have an option, but at the same time we’re working to make digital access itself more equal.
With the full support of our Executive Member, Morris Bright MBE, who was persuaded that part of our work was identifying what our role was in a world where COVID-19 has worsened health inequalities, we hope the strategy will set us on the road to tackling these inequalities and placing Public Health firmly at the centre of a forward-thinking council whose aim is to help our residents lead healthy, happy, and fulfilling lives. You can read the strategy here.
The Commonwealth Games took place in Birmingham 28th July to 8th August in (for once) balmy, sunny weather harking back to the days of the 2012 London Olympics. Here is an account of the final months of a five-year journey that UKHSA was a key part of, through three registrars who worked on the project:
Steve Barlow, ST3
Steve Barlow – Pictured on ‘Black Sabbath Bridge’ in Birmingham, along with Games mascot Perry, and Cassie Gregory, Principal Health Protection Nurse from the West Midlands Health Protection team
When I joined the Registrar training scheme in 2019, I never imagined that there would be a global pandemic. However, this provided me with a unique opportunity to observe mobilisation of a combined local authority (LA), UKHSA (then PHE) and wider healthcare response to an unprecedented public health type incident. Interestingly, this also helped in building relationships which then played out on another global platform: the Commonwealth Games (CWG).
As part of the CWG team, given my previous knowledge and experience, my main workstream was liaising with LAs and Integrated Care Boards (ICBs). As with all CWG work, it required degrees of overlap to ensure that the health protection response was as cohesive and comprehensive as possible. This involved a series of meetings to define and document the whole system preparedness should any health protection issue arise from CWG. Whilst some may consider this business as usual, we needed to streamline the system, to make the response more timely by calling on local relationships built during the pandemic.
Through leadership, advice and influencing, I worked on assessing any opportunities, good practices, and gaps in each area’s health protection response, looking at role and responsibilities, trying to clarify and agree these, and then share this information wider to develop more robust systems. I documented the current situation with a baseline survey and through our discussions, helped to produce formal plans for each local authority area. With support from the team, I then held a workshop for all the LAs in which over 80 individuals attended, to put plans into practise through a series of scenarios.
During Games time we were co-located in the Games Operational Centre (GOC) which was fascinating. Here we worked with a number of commercial partners as well as a few familiar faces. From the beginning, we became established (with our branded UKHSA branded, teal-coloured tops!) and, I believe, added value as we were able to assess and control situations in real-time. As part of the legacy work, I am evaluating the local partnerships workstream and looking longer term to make the health protection planning, commissioning, and response more cohesive in the wider health and social care system.
Clare Brehmer, ST4
Clare Brehmer – Wishing her children goodnight on the phone, with Games mascot Perry in the background, whilst working an evening shift in the Games Operations Centre
As the last member to join the core CWG team (fresh from maternity leave!) I was keen to “hit the ground running”. From the start the team were incredible to work with as there was nothing but positive vibes – all of us had chosen to work on the Games and were excited to showcase our work in the West Midlands.
My main workstream was to help develop operational plans for the laboratory testing during the Games period. One quirk of the Games was that there were pop-up polyclinics at five accommodation sites across the region, with a 24/7 motorbike service to courier samples to our UKHSA public health lab at Heartlands site. These services were set-up by the medical arm of the Organising Committee for the Games and provided routine medical services for all athletes and officials residing at these locations.
At UKHSA, we provided bespoke packs of consumables to each site, to be used in the event of an outbreak. We also developed a pathway for surveillance and reporting of any results related to the Games, and a round-the-clock rota for specialist laboratory technical and microbiological advice. This brought together staff from the public health lab, the local hospital lab, the CPHIs (Consultants in Public Health Infection) and health protection team, in a collaborative effort to streamline the testing and reporting processes for the Games period.
Our UKHSA public health lab also started providing Monkeypox testing for all Midlands samples a few weeks before the start of the Games; a useful addition to cut turnaround times should any potential cases arise.
The workload ramped up quickly, with extended hours starting a week before the actual start date of the Games, to allow for an enhanced public health response as athletes and officials entered the country. This meant we were all well-versed in the “Battle Rhythm” by the start of the Games. I was involved in the early preparations in the Games Operations Centre (GOC), meeting partners and introducing UKHSA to many people for the first time. Event planning is not something we often get involved in as registrars, and it was exciting to collaborate with others in health and safety, venues management and security to ensure all plans were in place. Several people even approached us to ask about careers in public health. During the Games I have to say, it was very quiet! We had heard similar reports from colleagues involved in London 2012 Olympics, but I didn’t want to jinx it. In reality, we had a steady workload of low-risk incidents and cases which rumbled along for the duration of the Games. This meant there was plenty of time for learning as a registrar and even acting-up as the public health adviser to the Games. As expected, there was a certain amount of politics involved and people management, at times with conflicting views. However, we continued to work effectively with our partners while providing sound public health advice and this undoubtedly contributed to ensuring a safe and successful Games.
David Collyer, ST3
David Collyer – With family enjoying the athletics competition at the Alexander Stadium pictured with England 100m sprinter, Imani-Lara Lansiquot
I joined the Commonwealth Games project team in February of this year, and early highlights (and opportunities to meet other team members in person rather than just on Teams!) were visits to the Lee Valley velodrome, and to the prospective athlete villages. Regular meetings of our core project team meant that we all had a chance to discuss our individual workstreams, get help and support, and maintain a good overview of all the work that was taking place.
One of my areas of work was participating in a planning group for ‘Health Protection Operations’ during the Games, which included leading workgroups for 2 areas in particular – plans for how we would work with the ‘polyclinics’ in the athlete villages and plans for how we would make use of the Medical Encounter System (a bespoke computer system being developed for the Games to capture medical data).
My prior experience of health protection work was limited, so this was a very steep learning curve, but planning a health protection response ‘from the ground up’ was an interesting way to get to grips with how the different elements all fit together. I also updated the Birmingham Airport Health Protection Plan (one of the main ports of entry for the Games) which included an appendix to cover the Commonwealth Games, particularly the COVID testing requirements for arrivals/departures. This required working with numerous stakeholders including the Organising Committee (OC) for the Games, the airport, the local authority, and other UKHSA teams including the Port Health lead, and the International Travel Contact Tracing team.
However, the most challenging and time-consuming area of work for me was around COVID and our recommendations for testing during the Games. The plans evolved considerably as the Games approached, and it was fascinating to see how decisions made by external stakeholders were influenced as much by politics as by epidemiology! As part of this work, I was able to attend a weekly meeting with the Chief Medical Officers for various UK elite sports, which had been convened early in the pandemic to facilitate a return to competition. This was a brilliant forum for discussing our COVID plans for the Games, as well as an amazing opportunity to hear the collective wisdom of an eminent group of sports medics.
Ultimately there were no big outbreaks during this Games, but I felt reassured that we had all the structures and processes in place to detect an outbreak and respond should it occur. Despite this lack of ‘action’ it was also fascinating just to be in the Games Operational Centre, watching as an event of this huge scale unfolded.
The Commonwealth Games Project Team was great to work with. Although the work was challenging at times, and definitely pushed me outside my comfort zone, I always felt well supported. I learnt so much during the 6 months and will never forget the buzz in Birmingham as the event we had spent so long planning for, finally came to town! I would recommend getting involved with a similar mass-gathering event, to any registrar offered the opportunity.
Caryn Cox, Lead UKHSA Health Protection Consultant for the Commonwealth Games
‘Having public health registrars embedded in the UKHSA West Midlands Commonwealth Games programme team and leading on key workstreams in the planning and preparation phase for the Games was fantastic. Each brought differing skills and knowledge to enhance the core programme team.
Clare, Steve, and David also each voluntarily stepped up in the operational phase of the Games competition time – working both the 6am early morning shifts and midnight finishing evening shifts and across multiple weekends.
They also undertook a rota slot where they were the Public Health Advisory lead in the Games Operational Centre, sat along with multi-agency colleagues. I hope they were each able to gain the development and learning opportunities they were seeking, as well as enjoying the experience and joy of being part of the largest Commonwealth Games ever held – held by all to be a great success.
As we capture the lessons learned from this Games to transfer to future events as well as internally in the UKHSA, we have already noted and recorded that registrars should, where possible and relevant to their training, be an integral part in planning, preparation and response, as opportunities such as these do not come along very often.
Our thanks to the triumphant trio, Clare, Steve and David, as well as Dr Alex Cockburn, an ST5 West Midlands registrar who worked on the Games prior to Feb 2022 and laid excellent foundations for other registrars to follow. We now hand over the baton to the State of Victoria, Australia for the 2026 Commonwealth Games’.
I qualified in 1965 and having sampled hospital clinical medicine in London and Cambridge for 3 years I decided that it was not for me – I neither enjoyed it nor found it particularly challenging (interestingly at University I was told that reading medicine was a waste of talent and that I should do something really scientific!). With a wife and three children by this time I looked for a job that allowed more time with the family and which paid more than a junior hospital doctor’s salary. It never occurred to me to become a GP which would have satisfied these two criteria and instead embarked on a public health career as a Medical Officer at the Birmingham Regional Hospital Board. This post which introduced me to health needs analysis and the planning of hospital services for a population of 5 million was not particularly interesting but it allowed me to embark on the formal training pathway to become a qualified public health practitioner. Although the London School of Hygiene and Tropical Medicine was then offering a brand new 2 year masters training programme, encouraged by my Scottish boss I applied instead for the Diploma in Social Medicine Course in Edinburgh which I obtained in 1971.
Then I very rapidly climbed the new career ladder in Community Medicine as it was then called and following posts in Wolverhampton, Stoke on Trent and Wakefield I was appointed Regional Medical Officer at the North East Thames Regional Health Authority. Not only was a regional post as high as I could go in the profession, the region I was appointed to was in a class of its own among the 14 regions in England – It was in a very real sense the dream job.
After 7 years in this job I got itchy feet and fortunately another NHS reorganisation saved the day by introducing general management. So, having had a long term interest in management and been sent to the US by the NHS for management training, I applied for and obtained one of the new District General Manager posts in Frenchay, Bristol where I stayed for three years. Falling out with my Chairman who was an import from industry who knew absolutely nothing about the NHS and healthcare – such wrong-headed appointments were all the rage with the Government of that time – I moved back to community medicine and obtained a post as DPH for the Norwich Health Authority which I held for 5 years before moving to Wales, initially as a Senior Lecturer in Applied Epidemiology and then as a locum consultant in public health with the Dyfed Powys, Swansea and Mid Glamorgan health boards and ending my career as the Public Health Director for Ceredigion and Powys Health Boards.
While working in Wales I joined the Labour party, became Chairman of the Socialist Health Association and for a period was a City Councillor in Bristol for a deprived ward in the south of the City.
The only time I felt that I was practicing real public health i.e. public wellbeing, as distinct from applied epidemiology, was when I was a Deputy Medical Officer of Health in Wolverhampton and later a Bristol City Councillor. In both posts I had a real sense that I was working in an organisation that could control at least some of the main levers of public health – or more correctly public wellbeing – for the benefit of the local population.
The main influences on my career were Gerry Morris, Bob Logan and later Julian Tudor Hart. In it’s origins the Faculty was a relatively inaccessible organisation, and as such I was very supportive of the Public Health Alliance and its successor the Public Health Association.
A mistake made by the Faculty at its inception in my view was to limit membership to doctors only, and whilst the Faculty now has a much more open membership, as a young community physician this prevented me from engaging with or supporting the Faculty at that time.
My own experience was essentially positive, probably helped by working as a GP and as an academic in other countries, and away from the PH service work so I came back with new experiences and perspectives.
I qualified first in Dentistry in 1965 determined to continue with Medicine and a career as an oral surgeon or in dental medicine. An oral surgery job in Scotland was interesting but not for a lifetime and returning to Medicine I became fascinated by Social Medicine. The teaching was uninspired, but I got to know Jock Anderson, the Head of Department and he helped me to think things through (everyone else thought I was mad)!
I qualified in 1969 and there were house jobs at Guy’s and Guildford but a desire to go to Africa where Jock advised I could get maximum experience across the spectrum. Wife, 3-month son, we sailed for Cape Town and on to Zambia…. On my return 3 years later he supported my application for the 2-year MSc at LSHTM. The MSC.in Social Medicine was designed for the new Public health role of the 1974 changes, and a different background and content from the DPH. It was two years, a whole year for a research project and enlightened teaching in Sociology, Economics, Epidemiology, Statistics, Management – but best by far the other people on the course, with a good deal of clinical experience but a genuine interest in a community and preventive approach with an understanding of information and to make for efficient and effective services within a cost envelope.
I was appointed to Tower Hamlets as DCP in 1976 and was there until 1981. I was single handed and also managed Infectious Disease/ hazards like asbestos. There were major health issues with homeless alcoholics with TB and Bengali immigrants in sweat shops, in squalid accommodation and with TB, Typhoid, Diphtheria…19th century stuff. Nobody quite knew what a DCP did, so I followed my instincts in a deprived part of London with a famous teaching hospital. I also worked quite a lot in the old MoH model with the LA, attending meetings, medical housing, school health…and the Winter of Discontent plus major industrial action by the Health Unions. Frank Murphy was at Area, you came to Region, Spence Galbraith had set up CDC Colindale – there was HIPE, HAA (neither very useful and full of errors) and RAWP
I persuaded the HA to let me do a year as a P/T trainee GP as the next re-organisation was coming. I had done a lot of locums by then as we had a young family, I was offered a partnership in Bedfordshire where we had done several locums and the practice agreed I spend 2 days a week in PHM my salary going into the practice earnings and I did 2 days a week in Luton working mainly in planning and supporting /deputising for the DCP (the unfortunate David Josephs who became a good friend and took his own life).
After 8 years as a partner we wanted to get away from the London orbit and after a few attempts got the DPH job in North Devon in 1989. We have lived here since. Again (as in TH) I was singlehanded and had time and space to do my own thing. (There were excellent secretaries, a registrar and information expert to help). Again I worked across the interface with the LA and in the MoH mode, this worked well and with excellent GP’s and Consultants, a new Hospital and no serious deprivation it worked well. I got much involved with the health problems of sheep dip in farmers. And the Cinderella services as we worked through Purchaser/Provider, contracts, and a new Trust.
When North Devon joined with Exeter, I did not get the DPH job and after several tries in Britain I went again to Zambia as an academic teaching Social Medicine and an MPH course for 3 years. There was quite a bit of clinical medicine too – I visited a mission hospital alternate weekends where there was no doctor. There was the chance for research too – I have always tried to publish stuff and with moderate success ever since Zambia in the 1970’s.
Returning to Britain in 1998 I could not get a job in PHM – too old, too experienced, a loose cannon… several long locums and the best a long appointment looking at rare diseases which cost a lot and have to be planned and organised at regional or national level. This was fascinating and with computers and enlightened statisticians it was possible to build costed models of care reflecting need, demand, and practice.
However when I had struggled to get work I had applied for an academic job in Papua New Guinea – they tardily got in touch and after some heart searching went again alone (dangerous for wives) to teach mainly PHM as an MPH but also a whole range of stuff to undergraduates – from biochemistry to forensic psychiatry…
On return, and I had my NHS pension by then, I did 5 years as a GP with the British Army and became involved with various national bodies e.g. NICE. Information Standards. The best things in PH to my mind – The CDC at Colindale, The Cochrane Foundation and NICE
I liked being in the NHS rather than the LA and being able to talk “doctor to doctor” with clinicians. I was working before the purchaser provided split and in North Devon acted as a personnel manager for the Consultants. I liked being between Medicine and Management and trying to explain one to another. On the whole I was lucky with Chairmen and Chief Executives who let me get on with things, more or less unfettered. It is now much more difficult, tight job descriptions not much room to pursue possible problems.
I think there were lessons to be learned for the Faculty in their response to Nuclear weapons and opportunities to challenge Government. The BMA Board of Science produced good science, Brian Jarman measured deprivation and health.
Other doctors in PHM, generally good experiences, (a few rogues, idlers, and villains but so it is everywhere) and excellent registrars, I helped to train. The newer younger GP’s and Consultants seem more open and easier now we need care ourselves!
I have been very fortunate; I am glad not to be working in the NHS now but also miss the struggles and occasional triumphs!
I retired from my main career within the public health system because I had stopped enjoying many elements of it; the benefits were not refuelling the tank that was being drained by the disbenefits I was experiencing.
Since retirement, I have taken two very part time roles. I was asked to stay on as a clinical advisor to the bloodspot screening programme for one day a week. This was complicated since the screening programmes also transitioned to NSHEI when PHE was abolished. It has taken me until now to be able to link in to some of the NHSEI Public Health arrangements and structures – over six months. I have also taken a role as Training Programme Director in the newly established Kent Surrey and Sussex School of Public Health, for half a day a week. This has been way smoother in comparison to the NHSEI role.
Having two part time roles makes it difficult to switch off from work sometimes, and I log in most days to check emails. Both roles are flexibly worked rather than having set times which I greatly prefer but which does allow the time spent on work topics to inexorably increase. I have started to book other things into my diary to keep this under control, and now spend more time catching up with friends, visiting art galleries, going to gigs, reading more and finally sorting the house and garden out. My longer term plans to travel more are starting to feel possible again as the covid situation eases, and meanwhile we have a summer of music festivals booked. My confident expectation that I would exercise more when I no longer had to rush to fit a swim in to an already long day hasn’t happened though. With all day to fritter away I some how haven’t got around to much exercise at all, and have started to book into more classes to make myself get more active.
My next decisions will need to be how long to continue in the part time roles I have. I feel I add less and less value to these roles as my other organisational knowledge becomes more and more out of date, and the effort of keeping up with requirements such as appraisal seems less justified. I suspect I will not be doing any formal work in a few years time, and am greatly looking forward to learning how to make cider from Dilys. My one attempt so far developed a very strange smell – will be trying again this year.
Could you please tell us a bit about your professional background and how this has led to you working on this series and stories
There has always been a creative seed deep inside me and, over recent years, my professional and creative worlds have become excitingly inter-twined. Professionally, I specialised both in general practice and public health, but the latter has been my mainstay for the past two decades. I have worked as a local director of public health at Camden, in national roles as director of public health strategy and global public health director at HPA/PHE, and am currently based at NHS HQ as clinical director for national clinical policy. I am also senior public health adviser to the Football Association (FA), advise the UK film/TV industry on Covid, and have worked academically at the London School of Hygiene and Tropical Medicine for many years.
As much as I have tried to be imaginative in my professional work, the creative seed has been slowly germinating. Early on, this was reflected by studying philosophy after my medical degree, but through the past decade the impetus has been increasingly expressed in literary form – further inspired by my involvement on the board of the wonderful national charity, BookTrust. In 2013, I published my first children’s book, The Amazing Adventures of Perch the Cat, and my current book, The Five Clues, was published by Crown House last year (https://www.crownhouse.co.uk/publications/the-five-clues).
The Five Clues is a YA detective/adventure book centred on 13-year-old Edie Marble, who discovers that her mother’s death a year earlier may not have been an accident. There is a public health plot (conceived well before the Covid pandemic!) and an important sub-theme around supporting mental health in children and young adults. The book – which is the first in the 4-book ‘Don’t Doubt the Rainbow’ series – has, so far, been short-listed for the Dudley Children’s Book Award 2021, People’s Book Prize 2022, Hampshire Book Awards 2022, and CrimeFest Best Crime Fiction Novel for Children Award 2022.
How do you think children and young people’s mental health has been impacted by the pandemic? And what are your hopes for how your books might be able to offer support to this group?
Today’s mental health challenges for children and young adults are immense. This was the case pre-2019, but since the pandemic the situation has heightened with significant rises in the demand for services for depression, anxiety, phobias, eating disorders, OCD, addictions and the like. In April 2021 the Royal College of Psychiatrists (RCPsych) said “the country is in the grip of a mental health crisis with children worst affected”. On 21 March 2022, the British Medical Journal reported that the RCPsych has now urged the government to fund a recovery plan for specialist mental healthcare due to “unprecedented demand”.
Against this backdrop, I have had a long-standing personal and professional interest in children’s mental health. In recent years, I have become especially interested in a new-ish approach to psychological wellbeing based on an understanding of how the mind works – and thereby an understanding of how we experience life, moment by moment and day by day. Awareness of how we generate our experience of life enables the reduction of psychological distresses (e.g. stress, fear, pressure, discouragement) and the uncovering of our inner well-being. The approach is therefore not just about managing life’s challenges, but also about facilitating the capacity for individuals to thrive and flourish. I have published articles in the Journal of Public Mental Health about this approach as well as a summary on my own Medium site (https://akessel.medium.com/the-three-principles-understanding-of-how-the-mind-works-an-overview-55c03a255296), and I sit on the board of a mental health charity that provides ground-breaking programmes (informed by this approach) to schools in this country and internationally.
In The Five Clues the young protagonist, Edie Marble, learns from her mum about this understanding, which helps Edie in solving clues, bringing criminals to justice, and navigating grief and other emotional challenges. This sub-theme of supporting children’s psychological wellbeing and resilience is threaded through the whole ‘Don’t Doubt the Rainbow’ series. In terms of public health improvement, my intention is to generate mental health benefit in the young using the vehicle of fiction.
How do you think story-telling more generally could be used in public health to reach certain audiences, particularly children and young people?
Story-telling is an incredibly powerful way of sharing ideas, conveying messages and effecting change. Much of what we already do professionally in public health involves telling a story. A well-written board paper tells the story of a new strategy to tackle obesity locally or the story of a proposed organisational re-design. To be successful such papers need a compelling story arc, in the same way as an impactful academic article tells a good tale of why the research is needed, how the authors set about conducting the study, what were the outcomes, and what should be done as a consequence. An annual public health report is, at heart, a chronicle of the health of the population.
If convincing, the narrative of a good story is more likely to capture the audience’s attention, and thereby more likely to be effective. This is just as true for a spoken story as a written one. Telling a story well is therefore a powerful, and somewhat underused, instrument in the public health toolkit. We need to harness this skill in public health, perhaps through first supporting development of the art.
Young people love a good story, perhaps even more than adults, and I hope that my children’s books can provide a touchstone to igniting deeper use of story-telling in the practice of public health.
Finally – are you able to give us any hints about what we can expect from the future books in the series?
Set three months apart, each book in the ‘Don’t Doubt the Rainbow’ series has a new adventure story, with the psychological wellbeing theme continuing throughout. The second book, Outside Chance, will be published in July 2022 and involves eco-terrorism, climate change, stolen dogs and exam fraud – as well as an over-arching discussion of determinism and free will. Plus, of course, Edie containing her journey of self-discovery.
I now spend a lot of time in schools – speaking to children and doing book readings – and at events focused on the relationship between fiction/reading and children’s mental health. It’s wonderfully enjoyable and rewarding, but nothing gives me more pleasure than a single child telling me how much they enjoyed my book and what they got from it. A story is an extraordinary vehicle for joy, entertainment and learning, as well as a potentially vital means to enhancing wellbeing.
In October 2017, I was honoured to present the Royal College of Physicians of London Milroy lecture.
In the lecture I described the potential benefits of four dividends for better health:
The Peace Dividend, the idea of ‘swords to ploughshares’- diverting military technology for peaceful, socially-useful purposes; an idea which took off with the end of the Cold War.
The Health Dividend, first described in three local Sandwell studies of anti-health vested industries and which came to be applied to the corporate citizenship role of health services.
The Inclusion Dividend, whereby design for disability in industrial and technological processes can produce better solutions for independent living for people with disabilities, but also for everyone.
The Green Dividend– where, for the protection of the planet, and for our health, we must look to the most environmentally-friendly use of energy and natural resources.
After the Cold War, politicians talked about the ‘peace dividend’ – the benefit that would arise from diverting investment, material resources, human intellect, and endeavour in war, towards peaceful, socially beneficial use. From 1986-1996, I was involved in researching Coventry defence industries and advocated alternative applications of the technologies for socially and environmentally useful purposes.
I applied the same principles in my work as Director of Public Health in Sandwell. There were industries with a vested interest in making people ill, which could diversify into less-unhealthy production and services, thereby delivering a health dividend. We researched local tobacco retail, the food industry and alcohol trade and proposed new models of production and services for food and alcohol.
Recognising human ingenuity and a drive for socially useful production led me to argue for design for independent living and for technology, which limited the impact of disability and promoted inclusion. Applying technology to the needs of people with specific handicaps can generate solutions, which are of benefit to the wider community. This we called ‘the inclusion dividend’.
In the era of global warming and climate chaos, a new green industrial revolution is needed, capable of delivering sufficient green energy to supply the world. It requires us to harness technological and socially useful production- for energy-saving devices, for renewable energy production, for energy storage, for energy generating buildings and for transport systems. In so doing, we can create jobs, create healthier living standards, and protect the global environment- the green dividend.
My lecture considered the relevant issues of diversifying health-damaging industry and harm reduction in issues which affect us today: Non-lethal weapons? The safer cigarette? Healthier eating? The non-polluting car?
Effort to engage with ‘Big’ business to find healthier alternatives is difficult and is fraught with pitfalls and dangers. Unhealthy big business will continue to profit from the misery they inflict on millions, and will continue to need regulation, taxation, and controls. “BIG” businesses will throw a smoke screen on the extent of their concerns for health and their efforts to create healthier alternatives, and we will be deflected and distracted. But dialogue, and challenge, and real diversification of industry is needed more than ever.
You can download the slides from the lecture here.
Sometimes I think politicians must be smarter than they seem when baying during Prime Minister’s Questions. I’ve spent the past couple years or so discussing pension reform with relevant actors within the social policy process (academics; civil servants; employers; politicians; professions; think tanks; trade unions) without realising that UK Members of Parliament had built an escape clause into the legislation. As Therese Coffey (Secretary of State for Work & Pensions) explained to the House of Commons last 4th December: Section 27 of the 2014 Pension Act demands a second Government Review of the State Pension Age by May 2023, for which already she has commissioned independent reports from Martin Clarke (Government Actuary) and Lucy Neville-Rolfe (Peer of the Realm).
If you look at the ONS Longitudinal Study, it is clear that at each decennial census since 1971 the proportion of women in their 50s who describe themselves in labour market terms (paid employment; unemployed; permanently sick; retired) has increased steadily, so it is reasonable that women and men should have the same State Pension Age, although why the gender difference should have been equalised up (first to age 65 years, now 66 years and soon 67 years, then 68 years) rather than down (to age 60 years), is less obvious.
The official reason is the increase in life expectancy during recent decades. One problem with this explanation is that the rate of increase in life expectancy now appears to have stalled and that, if and when it resumes, it is likely to lack its previous vigour. The bigger problem is that being alive is not the same thing as being capable of holding down a job; hence the need to think in terms of healthy life expectancy. Here the devil is in the detail and Lucy Neville-Rolfe has been tasked with adjudicating. John Cridland’s previous review opted to measure the healthy part of healthy life expectancy in terms of self-assessed health, although many consider that the absence of physical or mental disability would have been more appropriate.
I am one among the number who would prefer to see the State Pension Age linked to disability-free life expectancy, but my concerns are not limited to this technical issue. I am also part of an informal group of public health specialists who wish to draw attention to the possible unintended consequences of raising the State Pension Age and contribute to discussion of how to mitigate these.
Our concerns are that extending work-life may: (1) worsen the health of those with pre-existing illnesses; (2) overwhelm sparse occupational health and over-stretched general practitioner services; (3) hinder informal caring at a time when the need for it is projected to increase; (4) deter the volunteering which supports the NHS and the many charities upon which public health depends; (5) trigger overt disease in those with asymptomatic pathology or previous good health. Our report, detailing each of these items, can be downloaded free here.
We suggest that our concerns could be mitigated by [1] commissioning two pieces of research to establish (a) evidence-based triage criteria to guide occupational health & general practitioner services in deciding which older employees are most at risk; (b) whether extending working lives will increase the mortality risk of older employees in the most disadvantaged occupations. And [2] two changes to administrative regulations to accept (a) greater flexibility in the age range 60-68 years, to accommodate patterns of relapse and remission in chronic disease; (b) that paid employment is not the only type of socially necessary labour at these ages, with informal caring and volunteering as appropriate and legitimate alternatives.
Finally, there are issues of financial loss and workfare. Many of those now working until age 66 years spent most of their life paying their National Insurance contributions when its regulations increased the size of their State Old Age Pension in line with any years worked beyond the state pension age; the increase in the state pension age removed this entitlement, at a cost per person of up to £300 per month for life which, for Pension Credit recipients, could be the difference between living with or without the older person’s Minimum Income for Healthy Living. To add insult to injury, now these same individuals find themselves subject to conditionality (fitness for work testing) and sanctioning (benefit cuts), which those who saw the Dispatches report on the subject (Channel 4, 17th December 2021) will find it hard to believe that MPs intended when they voted through the 2014 Act.
David Blane Professor Emeritus of Imperial College London
CORRECTION WITH APOLOGIES
“all three of whom, it may be relevant to note, will be entitled to solid gold pensions when they retire (non-contributory, defined benefit, final salary).” – removed from final line of Paragraph One.
Civil service and parliamentary pensions are contributory (at 6% of salary) and paid on the basis of career average salary; inflation-indexed defined benefits remain.
The Yorkshire and Humber speciality registrar committee spent time reflecting on 2021, with a focus on the challenges we have faced and the positive things which have supported wellbeing. The COVID-19 pandemic has seen working from home become the norm for many public health professionals, and this was prominent in our conversations.
Office for National Statistics (ONS) show that the proportion of working adults who did any work from home increased in 2020, and 85% of those currently homeworking wanted to use a “hybrid” approach of both home and office working in future1. If working from home is to become a norm of working life, we must work together to support wellbeing.
Challenges
The pandemic has had a profound effect on everybody. There are some aspects which we cannot control and must live with. This can leave us feeling quite bleak and such feelings are particularly prominent at times when restrictions change.
Many registrars have undertaken placements without meeting their colleagues in person. A lack of human interaction face to face left people feeling disconnected. There is more challenge in building relationships with colleagues and partners.
The line between work and life can become blurred. People might be working at their dining table or in their bedroom. As well as this physical blurring of work and home, there is a psychological blurring too. There are back to back meetings which might not leave much time for admin and replying to emails. It is “easier” to start early or stay late. It is “easy” to pop back to your work area.
Culture and leadership really set the tone for wellbeing. In Yorkshire and Humber, registrars receive regular wellbeing check in calls from the Head of School and Training Programme Directors. I extend thanks on behalf of the registrar body to the School of Public Health Team for their support and for setting the tone for a positive culture. These tips are based on experiences in our region which have been helpful.
Top tips to support wellbeing for organisations and leaders
Create mini breaks by starting meetings at five past the hour
Encourage protected time for lunch, including getting outside during day light hours in winter
Encourage meeting free time each week (e.g. 1 meeting free day per week)
Thanking people for good work they have done
Flexibility in working hours
Hold regular meetings that help teams to keep in touch (e.g. weekly registrar catch ups)
Offer walking meetings using telephone rather than video conferencing where able
Mosquitoes winging their way north across Europe bringing dengue. Floods and drownings. Heat stress. Despair. We are all aware of the health impacts of climate change. But how do we get governments to act? Ballot box pressure (in democracies) does not guarantee results as shorter-term concerns distract from our overheating planet. No easy answers, but experience from the environmental movement provides clues and inspiration.
On 7 October the Faculty of Public Health co-hosted a webinar on Public Health, Climate Change and Strategic Litigation (recording now available online). It aimed to alert public health academics and practitioners to the opportunities for legal action to hold governments and private sector polluters to account for health-harming pollution and climate change.
Moderated by Dr Farhang Tahzib, the webinar attracted over 800 registrations from around the globe. Starting close to home, Rosamund Adoo-Kissi-Debrah recounted how air pollution in London led to the death of her daughter, Ella. Sir Stephen Holgate gave expert testimony at the coronial enquiry into Ella’s death. He noted how air pollution is now largely invisible and hence neglected – yet ‘breathing clean air is a right, just as we have the right to clean water.’ Dr Maria Neira, WHO’s climate change and health champion, presented the ‘health argument for climate action’ that WHO will take to CoP26.
But governments have long been aware of the short- and long-term health impacts of pollution. What else can be done? Strategic alliances between public health actors, environmental activists and legal academics and practitioners are using court action to highlight government inaction and industry abuses. Marlies Hesselman, lecturer at the University of Groningen, Netherlands, gave a ten-minute ‘strategic litigation 101’, noting four recent and current cases where governments have been called to answer before international courts and tribunals for health harms related to climate change. Irmina Kotiuk, senior lawyer with ClientEarth’s Clean Air Program, noted the huge role for public health specialists as experts in strategic litigation – building on the experience of tobacco and asbestos. She urged nurses and doctors to collect and record evidence in medical files which can later be used in expert testimony.
Richard Harvey, barrister and legal counsel for Greenpeace, drew parallels between tobacco companies’ now infamous denials of the link between smoking and ill-health, and today’s spin from fossil fuel companies. The Dutch District Court in The Hague was not fooled – in a landmark 2021 decision it ordered Shell to reduce CO2 emissions by 45% by 2030, globally. Dr Marina Romanello, Research Director for Lancet Countdown, reiterated the health impacts of climate change and the continuing financing of the destruction of our health through fossil fuel industry subsidies.
Yet the Lancet Countdown 2021 report on health and climate change: code red for a healthy future, makes no reference to the role of the law (other than to the International Health Regulations), let alone to the hundreds of current and recent legal cases on climate change alone, easily searchable through online databases. Restating the problem in ever greater detail is not a strategy for change. We need to combine the credibility of hard science with the legal skills of seasoned national and international litigators and the experience in social mobilization tested and proven by other social movements – all adapted to today’s online, COVID-19 constrained world. Dr Neira remarked that ‘People working in the environment say we need to hear more from the public health community – because you are still trusted – politicians will listen to you.’
Bridges between the public health, environmental and legal communities must be strengthened if we are to ‘keep 1.5 alive.’ The 7 October webinar was co-hosted by the Global Health Law Groningen Research Centre and the ‘law and public health’, ‘environment and health’ and ‘ethics and public health’ sections of the European Public Health Association. Section membership is free and not limited to public health practitioners or people resident in Europe.
The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.
Better Health For All 