Better Health For All

None of us can envisage how the complex adaptive system of planet Earth and its ecosystems will develop over time, but one thing is certain – that our planet, and the human societies, animals and plants which inhabit it – will change in ways which are unknown and unknowable. The dominant cultural paradigms of modernism and postmodernism which have defined public health practice are being replaced by a new paradigm which is increasingly referred to as ‘metamodernism’. Public health leaders are ideally placed to shape this slowly evolving cultural revolution, and will also need to attend to their own development to thrive.

Human beings have lived in societies and created culture for at least 40,000 years. Cultural  ‘memes’ (non-biological units of cultural transmission) are spread between human beings by communication: similar to a virus becoming endemic, some memes take off within a society and become dominant. Memes which become dominant may go on to define a broader paradigm (‘meta-memes’) and thus define a society, we regard such meta-memes as being the symbols and signs of a society’s ‘culture’ (as represented by their forms of art, literature, music, philosophy, religion and science etc).

The spread of cultural paradigms is not even within a society, nor can a paradigm be readily contained within specific time periods as discussed by the authors under the pseudonym of Hanzi Freinacht. The cultural paradigm which has increasingly dominated Western society for the last few hundred years (‘modernism/scientific rationality’) has its roots in the 17^th and 18^th Century Renaissance, Scientific Revolution, and Enlightenment periods. While one cultural paradigm may dominate a society, nation, or group of nations, as in the example of modernism, there are actually multiple paradigms co-existing globally – and also within a nation or even within a local society – at any one time. For example, the range of cultural beliefs within societies and individuals across the planet currently spans from ‘animistic’ (tribal society with magical and ritualistic thinking) through multiple paradigms to ‘post-modern’ (criticism of the rational, scientific thinking of modernism). This presents a challenge to public health leaders, whose endeavours to improve the health and wellbeing of local communities and national populations cannot, as we know, ever be a one-size fits all. This is before we even consider the additional issue of stage of adult development of individuals within a society.

Each new cultural paradigm has brought some degree of improvement to the health and wellbeing of people and the planet. However even the most well-intentioned moral projects resulting in new and seemingly ‘better’ paradigms have brought unintended negative consequences of their own: every paradigm contains ‘the seeds of its own destruction’. Freinacht reminds us that modernism has led to further inequality, alienation and ecological collapse, and that while postmodernism has provided a narrative in response to oppression and inequality, it has largely failed to have impact.

There is evidence, especially in Nordic countries, of an emerging new cultural paradigm which public health leaders may wish to consciously pay attention to, in order to shape its direction, to enhance the benefits and to mitigate the unintended, inevitable, negative consequences. It is a paradigm evolving under the names including post-postmodern, TEAL, integral, and increasingly referred to as ‘metamodernism’.

Metamodernism is a perspective which transcends and includes many aspects of previous paradigms, and is based on complexity, emergence, and dialectical thinking. Individuals are seen in the context of transpersonal networks integrated with the planetary ecosystem, ie both autonomous and indivisible from others and the whole.  Descriptions of a possible metamodern society are based on ideas of cultivating new forms of social welfare – building societies where people feel heard and valued, with a focus on adult development and psychological wellbeing. Metamodern politics focuses primarily on process, in order to ensure that all people can flourish and thrive – and all of this in a way which is open, democratic and without ‘being controlled’. As public health leaders, we know that this must be underpinned by the essential needs of food, security, income, and other key determinants of health: and yet there is also increasing evidence that people with, for example, poor mental health can also experience high levels of wellbeing, and vice versa.

Public health professionals have always worked at the forefront of new ideas and new paradigms, working across systems, organisations and communities in service of their populations. In order to lead in the context of new, post-postmodern cultural paradigms, public health leaders will need to grow their own forms of mind to embrace the metanarratives of metamodernism.

Dr Fiona Day is a former Consultant in Public Health Medicine, now working as an Executive Coach offering world-class coaching for senior doctors, medical and public health leaders in the UK and internationally. She specialises in using adult development theory in the context of complexity to enable leadership development.

What is COP 26?

We are hearing a lot about COP 26 these days, so what is it? It is the next annual UN Climate Change conference. COP stands for Conference of the Parties and the meeting will be attended by the countries that signed the United Nations Framework Convention on Climate Change (UNFCCC) a treaty that came into force in 1994. 194 countries ratified the treaty.

COP 26 is happening in Glasgow in November 2021. It should have been in 2020 but was postponed due to the COVID-19 pandemic. It will be hosted by UK and Italy. There is still some debate as to whether the meeting will be partly ‘virtual’ due to the continuing issues of the pandemic.

COP 26 is significant as it is 5 years since the landmark Paris agreement and is the first time countries will come together to renew commitments to strengthen the ambition to meet the 1.5 degree target agreed at the Paris COP in 2015.

Each country has to produce a NDC (Nationally Determined Contribution) outlining what they will contribute to the global reduction in emissions towards net zero by 2050. Most NDCs need to be more ambitious than they are at present and the delay to COP 26 has given an opportunity for countries to revise them. UK has recently produced a revised NDC. During the Leaders’ Climate Summit, hosted by President Biden on 22 April, USA published an ambitious NDC, including the commitment to achieve an economy-wide target of reducing its net greenhouse gas emissions, and other countries also made further commitments. However taken together they still do not get us to the target.

Why is it important for Public Health?

Climate change is a public health emergency, as FPH recognised in 2019. The response to the COVID-19 pandemic has shown how countries can respond to a health emergency and the science shows the next 10 years are critical if we are to respond effectively to the climate crisis. Climate change has serious health impacts but there are also important co-benefits of addressing the environment and climate issues and addressing health, for example in the area of clean air, active travel, diet and nutrition.

The issues of climate change, biodiversity loss, environment degradation, and sustainable development are inextricably linked and underline the need to take a One Health approach to population health. 

The international health community has been trying to ensure that health issues are more centre stage in the NDCs and also centre stage at COP 26.

Climate Change is the biggest threat to health.

There are major health impacts of climate change, not just across the globe but also here in UK. Floods and severe weather conditions cause both physical and mental health impacts. Only last week we saw the landmark ruling, with air pollution recorded as a cause of death for the 9 year old Ella Adoo-Kissi-Debrah, who died of an asthma attack in 2013.  This is due to emissions, mainly from cars and lorries. Air pollution accounts for 4.2 million deaths per year globally and 40,000 across the UK.

This pollution is happening now in our cities. Many areas in the UK do not meet the WHO standards for air quality.

We all as PH professionals have a responsibility to make the connections between everyday health issues and climate change, and address both, tackling them together. 

Why now?

Whilst the COVID-19 pandemic has hit the globe in the face, climate change is the other big emergency that is hitting as we speak. Besides air pollution, we are already seeing the out-of-control wildfires in Australia and USA, and islands literally disappearing with rising sea level.  We are seeing extreme weather conditions across the globe and in UK. Wildfires happened last week in UK due to the lack of rain and floods regularly cause major problems across the UK with some families not back in their homes 18 months later. 

The Biden summit last week was seen as the first marker for COP 26 and has been welcomed as it signals the USA being back in the Paris agreement and working with other countries on climate issues.  

We have to act NOW if we are going to stop these health impacts and we have to act locally, nationally and globally.

The run up to COP 26 gives us an opportunity to think differently about this both as individuals and in our professional public health lives. Many recognise that sustainability and climate change issues need to be a day-to-day part of our public health practice and we need to act now.

As Greta Thunberg said earlier this week on the BBC “Hope doesn’t come from words, it comes from action”.

Sue Atkinson
Chair, FPH Climate and Health Committee

For over four years FPH  has sought to inform the national debate about leaving the  EU and  when  the decision to leave was made, we have sought public health protections. Our ‘Do No Harm campaign to retain the Lisbon treaty protections for  health, our  campaign to stay with European public health protection agencies like ECDC and  ECCMDDA and our work on healthier trade agreements can all be  found on the FPH website. Our webinar in October highlighted our continuing concerns about leaving the EU without a deal.   

Through November we have sought a dialogue with Local Resilience Forums (LRFs) to see just how realistic Brexit  planning is in the era of pandemic.  LRFs are the delivery vehicles of local preparedness under the 2004 Civil Contingencies Act. The Act was brought in after multiple national emergencies involving floods, fuel strikes and  foot and mouth. LRFs were required to address ‘all risks’  in major emergencies.

Reasonable worst case scenarios

Even in the summer of 2019 FPH  was expressing concerns that the UK was not prepared for Brexit, with or without a trade deal.

Operation Yellowhammer, the Reasonable Worst Case Scenarios (RWCS) for Brexit planning were published August 2^nd 2019.  These anticipated a departure from the EU, in the autumn of 2019. They also had no expectation that a pandemic would happen, and  interfere with every piece of national, international and local planning for the Brexit move.  Brexit on its own, was going to be the biggest ever emergency planning exercise across all elements  of civil society and  private sector activities.

LRFs in the pandemic

We now face a perfect storm of a new COVID  pandemic escalation, a cold winter and a crash out Brexit. 

During the current pandemic LRFs, and their constituent  members have been run-ragged,  by the understood requirements of the pandemic, but also by the conflicting and contradictory pronouncements of central government . There has been nothing to relieve this situation since then.  The C19 National Foresight group is a cross-government organisation working with partners to support Local Resilience Forums (LRFs) in response to COVID-19. In May 2020, their leaked report criticised the government’s “paucity of information and intelligence,” which left LRFs, such as councils, police, and medical professionals, “isolated from national decision-making and unable to effectively plan and strategise response[s].” C-19 also described ‘responder community exhaustion’. And added that an additional extreme risk, as posed by a crash-out Brexit, would take them to breaking point. 

The information from central government as shown in the RWCS is clearly inadequate. Nothing has changed since May 2020 to reduce the risks or burdens on local emergency planners with regard to Brexit; it has only become more difficult.  They are in a position of responsibility without power – where they should be the key local body- coordinating, acting, responding, they, like many others are awaiting  central instructions.

LRFs have been planning on the basis of the Operation Yellowhammer RWCS, published on 16 months ago. The RWCS were deeply flawed even in 2019. Some of the omissions are shown in Box 2. Now, the planning parameters have become much worse…An autumn planning scenario for no deal Brexit had been replaced by a winter point for the action- and there is no evidence of planning for a severe winter.  Risks interact- there a plan for a COVID outbreak amongst Border inspection services or for Covid amongst hauliers.  Another multi-impact risk has  been seen with the world wide shortage, and mis-placement of containers, compounded by a massive inflow of container based imports of PPE for the NHS, and  stockpiles of other goods for commercial sale.   Extreme traffic congestion and incomplete facilities on the M20 add risks environmental damage- through air pollution, noise and insanitary conditions,  distressing  conditions for hauliers causing driver frustration, mental stress and localised anger and disorder issues of the ‘road rage’  variety.

There are a multitude of component or service failures which could happen and won’t  be recognised until they happen. Serial and multiple incidents have the potential to conflate as a ‘slow burn’ economic disaster with widespread social and environmental impacts. Combined with actual civil disasters the impact will be more severe, and the capacity to respond  will be impaired.

Central government has excluded local partners from key intelligence and fails to share enough information, as it has with coronavirus. According to the C-19 group, LRFs said central government mainly engaged in ‘broadcasting,’ with communication ‘only one way’.

Local Resilience Forums are limited in the extent  to which they can plan for the EU Withdrawal, with or without a trade deal.  The National RWCS were the start point of their planning considerations and that should give us very little assurance of  our state of preparedness across the country.

And now…new variant  COVID-19

The arrival of a new variant SARS-Cov-2 virus is by Secretary of State, Matt Hancock’s admission ‘out of control’ . This is a new escalation of the already exhausting COVID-19 pandemic. We believe the government should acknowledge that this new development on the COVID-19 pandemic is so grave and requires such significant resources and attention by public health and economic authorities that there should be an agreement to defer the departure of the UK from the EU.

We say this not as pro-Europeans playing  politics, but as experts in public health with years of experience in emergency  preparedness and response.  There would be no shame and no disgrace or political weakness shown by either side in the  Brexit trade negotiations if they simply agreed to extend the period of transition.  Indeed with regard to the safety of the  public, it is the only safe way to respond. 

Professor John Middleton
Immediate Past-President FPH
President of ASPHER

Professor Maggie Rae 
President of FPH

Do you influence the way resources are allocated by Public Health in the NHS and Government?

Are you up to speed with the answers to the following questions?

• What guidance would you use when procuring goods and services?
• What are the main sources of emissions in the NHS?
• Describe four potential areas for action to reduce NHS carbon emissions

Check your knowledge and reflect on your actions as Public Health professionals by reading the latest resources available on the Faculty of Public Health website as follows:

Resource K9 – The NHS: Carbon Footprint

Resource A9 – Towards a Net-Zero Carbon NHS

Resource A7 – Sustainable Planning, Procurement and Commissioning

The resources will help you to deliver better services, complete your Public Health competencies and reflect on the contribution you can make to the Government aim of reaching net zero carbon emissions targets by 2050 in England and 2045 in Scotland.  Check them out at the Faculty of Public Health website here .

Thanks very much to members of the FPH Sustainable Development Special Interest Group and to Jenny Griffiths as editor in chief and all authors for their contributions to these resources.

Helen Ross
Chair FPH Sustainable Development SIG

Like other SIGs, the FPH Film SIG was caught off guard by the COVID pandemic. At the end of 2019, members of the SIG had been working with the British Council and UCL to screen films on children health at its first event in India. However strict lockdown measures quickly put paid to live film screenings and opened up a unique opportunity to collaborate with the Public Health Film Society (PHFS), the Government of India and the American Public Health Association (APHA) to collect stories of the pandemic told through film.

With the support of FPH President, Maggie Rae, we helped launch the International Public Health Film Competition 2020, only 46 days after the World Health Organisation (WHO) declared the COVID-19 pandemic on 20th April 2020.

In total 1746 films from 112 different countries were gathered through the film competition, of which over 440 films were specifically related to COVID. It was incredible to see film-makers rising to the challenge of telling stories about the pandemic despite the many hurdles to film production during the lockdown. The FPH recognised this challenge and offered to sponsor a prize for the ‘Best COVID film’ submitted through the competition.

This prize was won by Yohana Ambros for her film ‘Buonanotte/Goodnight’, a moving personal tale of being homelessness in Milan, the epicentre of the pandemic in Europe.

The judges prize went to Javier Robles Álvarez, a young film-maker for his first film ‘MANUEL’, a thought provoking reflection about family time and forgetting, incidentally also made in Spain during the constraints of the pandemic.

Both films will be shown alongside a discussion with the film-makers on 4th December 2020, as part of The Oxford Research Centre for the Humanities (TORCH) virtual ‘Big Tent – Live Events Programme’, and the International Science Film Festival of India in late December.

However if you are not able to make any of these screenings, then you can watch the film trailers on the FPH, PHFS or TORCH website.

Lastly, we would like to extend a special thanks to the film judges for kindly gave their time without which this project would not have been possible.

Nimish Kapoor, Senior Scientist and Head, Science Film Festival Division, Vigyan Prasar, Department of Science and Technology, Government of India

Kartik Sharma – Filmmaker and founder of Public Arts Health & Us (PAHUS)

Patrick Russell, Senior Curator (Non-Fiction), British Film Institute (BFI) National Archive

Linda Bergonzi-King, MPH, Co-Organizer of the American Public Health Association Global Public Health Film Festival; Producer/Director/Consultant at TriBella Productions

Dr Stephanie Johnson, Research Fellow in Global Health Bioethics at the Wellcome Centre for Ethics and Humanities, University of Oxford

Professor Maggie Rae, President of the UK Faculty of Public Health

Dr Olena Seminog, Vice-President, Public Health Film Society, Nuffield Department of Population Health, University of Oxford

Blog written by Uy Hoang
Chair, FPH Film SIG

4.11.20

Well today is a strange day. There’s a lot going on. 

It was the USA presidential election yesterday and we awoke today expecting the results, but, as I write, it is neck and neck and there is no clarity – certainly no landslide for either Biden or Trump. We have to wait and see when all the votes are counted, despite Trump trying to get some of the postal votes not counted. It doesn’t bode well for a quiet transition.  

Today is the day that the USA formally leaves the Paris Agreement on climate change. The election result will of course have an impact on that. If Trump wins then the withdrawal will remain, with all the global impact that that might bring. If Biden wins then he has said he will reverse that decision and rejoin the USA into the Paris agreement.  For those who know me and my passion around health and climate change then there would be no guess as to which outcome I am hoping for.  (Late note added 8 11 20 – Joe Biden has won and has already said he will rejoin USA into the Paris agreement .. hooray!)  

It is 5 years since the Paris agreement and today is the first Earthmedic and Earthnurse day …. “EarthMedic and EarthNurse are focused on health and environment-related concerns, with the goal of being a home for nurses, doctors and others, concerned about the climate and health emergency we face”  

This morning the UKHACC, (UK Health Alliance on Climate Change) – the Alliance of health care workers members organisations in the UK eg. the Royal Medical Colleges, BMA and Royal College of Nursing etc. (the FPH was a founder member in 2016) has launched their report on Building a Healthier Food System for People and Planet –  “All consuming”   http://www.ukhealthalliance.org/wp-content/uploads/2020/11/UKHACC-ALL-Consuming-Building-a-Healthier-Food-System-for-People-Planet.pdf 

We were reminded that agriculture and food is responsible for over a quarter of global emissions. The production of red meat outweighs most other  food production and utilises 77% of land use on food.  

Eating more plant food makes a huge difference to the environment and the planet and is, of course, better for our health.  Please reduce your meat intake.   

Through the new FPH Climate and Health Committee we will try to bring in some actions that may make a difference to food consumption and waste.  

And if that isn’t enough for today, it is the day our MPs have voted for emergency measures for those of us in England to go into lockdown again tomorrow. The aim is to try to control the rising numbers of Covid-19 and get the R number back down to less than 1. Let’s hope it works.  

Sticking to the rules for lockdown is important. All of us in PH understand that.  

Unfortunatley not all of the English population (or even some MPs) seem to understand that. We shall have to wait and see what happens over the next month.  

So on that note, of two major global health issues – Covid-19 and climate change…I am sure tomorrow will be less action packed, as we all start into our routines of lockdown again  – most importantly –  stay safe.   

Sue Atkinson
FPH Board Member and Chair, FPH Climate and Health Committee

4.11.20

The health burden of the current pandemic will extend far beyond the direct impact of COVID-19 morbidity and mortality. We must use evidence to mitigate the wider, indirect effects to protect and improve the long-term health of our population.  

The UK has recently recorded increases in confirmed cases, hospital admissions and deaths from COVID-19. A second wave of the pandemic, with severe health consequences, is underway.  

Leadership is needed to reduce both direct and indirect harms to population health. Unfortunately, political and scientific debates have been unhelpfully framed as a trade-off between controlling the pandemic and minimising the wider consequences of our policy response. In fact, we need both a strong direct response to the pandemic and strong measures to mitigate its indirect impacts. However, the role of evidence-based public health leadership has been much clearer in the former than in the latter.     

This lack of clarity matters because the indirect health effects of COVID-19 are substantial. Frameworks published in April and June anticipated and outlined an array of short, medium, and long-term health and equity effects arising from the pandemic and resulting control measures. There is now a growing evidence base modelling the scale of these impacts or demonstrating them in practice.  Some effects have been felt already, and some will be seen in the long term. They include: 

• displaced healthcare services, and decreased use of remaining services, for example leading to excess mortality from cancer or cardiovascular disease in addition to wellbeing impacts from losses to community services.   
• mental health effects – including in children – arising from social isolation, uncertainty, economic insecurity, bereavement, anxiety about exposure to the virus and working conditions 
• changing or inequitable access to green space, physical activity and healthy food; and new patterns of alcohol use, smoking and gambling  
• changes in exposure to environmental health hazards including overcrowded or poor-quality housing, or temporary accommodation  
• economic and employment impacts, which are inextricably linked with health outcomes
• long-term effects on the life chances and health of a generation of children and young people arising from educational disruption, loss of social contact, missed safeguarding opportunities, and exclusion from the workforce. 

Just as there is evidence that the direct effects of COVID-19 are disproportionately felt by some social groups, there is also evidence that the indirect effects harm some more than others, often reflecting existing inequalities. The initial weeks of lockdown in the UK saw a clear socioeconomic gradient in adversities related to basic needs such as access to food and medication. Consequences for Black, Asian and Minority Ethnic communities have also been profound. Impacts on other groups may be specific to the current crisis: for example, young workers, women, and low earners are more likely to have been employed in sectors that were shut down as part of the government’s response.  

Importantly, there are national and local examples of measures to mitigate potential risks to both short and long-term population health. National and regional initiatives include tenancy protection for renters, emergency accommodation for rough sleepers and job protection schemes.  

A second wave brings an urgent need to draw on this evidence and good practice about the indirect population health impacts of COVID-19 and how to mitigate them. As policies and support schemes change, focus is needed on populations that may become newly vulnerable. But at the time this analysis is most needed, the capacity to carry it out is insufficient at both national and local level.  

Technical advice to UK governments comes from the Scientific Advisory Group for Emergencies (SAGE). SAGE has multiple subgroups ranging from epidemiological modelling, to behavioural responses, to infection control. It does not have a subgroup on wider public health consequences.  

Public Health England should be the organisation best placed to consider wider population health in England. It has produced useful resources to understand and mitigate the pandemic’s impacts. However, it is being disbanded and the future of its health improvement functions remains undecided.  

At local level, Directors of Public Health have an important leadership role. Unfortunately, their teams have seen their long-term resilience eroded by funding cuts, and many frontline staff have been diverted to support the direct pandemic response. Other public services including healthcare, social care, education and housing have an important role here, and are also stretched. 

National, regional and local public health capacity is needed now to help translate evidence of the wider pandemic impacts into concrete action across different sectors. If we fail to learn from the first wave, we risk exacerbating the impacts of the pandemic and doing unnecessary harm to mental and physical health for years to come. 

Written by

Emily Humphreys, Imperial College Healthcare NHS Foundation Trust (@emilyjhumphreys) 

Hannah Barton, Imperial College Healthcare NHS Foundation Trust (@Hannah_EB1) 

Ellen Bloomer, London Borough of Newham  

Fran Bury, Imperial College Healthcare NHS Foundation Trust (@audacityofboats) 

Aideen Dunne, Imperial College Healthcare NHS Foundation Trust (@dunnea9) 

Katie Ferguson, Imperial College Healthcare NHS Foundation Trust  

Suzanne Tang, Imperial College Healthcare NHS Foundation Trust (@suzannestang) 

This article is based on the findings from a series of rapid evidence reviews and consultation conversations with key London stakeholders, exploring the wider impacts of the pandemic and the considerations for recovery, within the context of improving population outcomes. The full report is available here.

This is anything but a typical year and we all want to protect ourselves and those close to us.

Receiving the flu vaccine is more important than ever before because of co-circulation of COVID-19 and flu. The flu vaccine will help reduce pressure on health and social care during a challenging time and by reducing transmission of flu, help to protect some of the most vulnerable in our community. Those most at risk from flu are also most vulnerable to COVID-19. We must do all we can to help protect them this winter.

Therefore, the Health and Social Care Workers flu vaccination campaign is more important than ever. The flu virus spreads from person-to-person, even amongst those not showing any symptoms. For frontline workers, there is an increased risk of contracting flu and it’s very easy for individuals to pass the virus on without knowing. Even if they’re healthy, they can still get flu and spread it to the people they care for, their colleagues and to their family. This year, more than ever, we are stressing that getting the flu jab is simple, easy and free to those eligible.

For the campaign we carried out research to understand health and social care workers’ barriers to and motivations for getting the flu vaccination in this unusual environment. The research brought out the need to promote a protection-based message, as well as the message that many with the flu can be asymptomatic. This insight has helped shape our creative, communications, and partner assets to ensure they are effective as possible in encouraging uptake of the flu vaccine. Also, a new range of adaptable materials have been provided to allow communication teams to promote local information or new ways for staff to get vaccinated. We knew the flu vaccination may be offered in slightly different ways than previous years, whether that’s easier access for social care workers or hospitals hosting vaccinations in an outdoor marquee!

Due the current environment and the extended eligibility of the social care workforce, we’ve worked even more extensively with Department of Health and Social Care (DHSC) and NHS England & Improvement (NHS E&I). We want to ensure that all communication opportunities are being used to engage and that the sectors are aligned. This can be seen at campaign launch where NHS E&I released an open letter from senior clinicians, sent to all NHS frontline staff alongside a short video by Chief Nursing Officer, Ruth May, promoting the programme. DHSC also released a video from Deputy Chief Medical Officer, Prof. Van-Tam and sent targeted communications to social care organisations and workers.

The Health and Social Care Workers flu vaccination campaign launched on the 16th September and has attracted widespread positive attention from the start with comment from Secretary of State, content across trade media, social media as well as communications from employers, sector stakeholders and representative bodies. There has already been a huge increase in demand for campaign resources, with some assets seeing well over double the amount of orders compared to the previous year. For anyone looking to deliver their own local Health and social care worker flu vaccination campaign, please visit Public Health England’s Campaign Resource Centre for access to toolkits, campaign resources and more.

Written by Public Health England

A summary  

More than 350 people registered for the Faculty of Public Health emergency webinar on the impacts of a Crashout Brexit on October 19^th.  They came from more than 20 countries  and  three continents reflecting the huge international as well as UK interest in this imminent potential disaster.  The webinar was made all the more timely by  growing  concerns about the risks of a crash out,  from food, manufacturing and haulage sectors. The Prime Minister’s speech on October 16^th made the subject all the more urgent and compelling.   

Professor Tamara Hervey, Jean Monnet Professor of European Law at Sheffield University presented current legal implications of Brexit and crash out. The European  Union is a rules-based organisation. The European Parliament must agree trade deal proposals recommended by the European Commission for implementation by January  1^st 2021.  So time runs out soon. Key sticking points are fisheries, ‘level playing field’, and the governance of the agreement. We risk a crash out  Brexit by default, or by accident. No deal means trading by the World Trade Organisation’s rules, which do not prioritise health. Tariffs are automatically applied on traded goods. The EU has published over 100 sector-specific stakeholder preparedness notices during the Article 50 negotiations with the United Kingdom, suggesting it is serious that no deal could happen. Even if a deal is struck there is no provision for cooperation on broader public health matters, such as tobacco regulation or communicable disease control. Brexit, and specifically the UK Internal Market Bill, affects Scottish and Welsh government aspirations for Continuity with European regulations and may jeopardise existing public health measures there, such as minimum alcohol unit pricing. 

Dr May Van Schalkwyk reprised some of the concerns of her paper with the FPH president and others and added in a few more up to the minute and with a COVID pandemic now added to the mix. Uncertainty always affects mental health. Multiple shocks as we would potential see with Crash-out Brexit on top of the COVID second wave would compound and accelerate each other. A poor or weak deal would only be marginally better than no deal in terms of the disruption anticipated at our ports and the far reaching negative impacts on our economy. There would be disruption to  trade and to supply chains in many aspects of the  economy and important  institutional  links will be weakened or broken. There is strong possibility of shortages of food,  medicines, and components for manufacturing industry. There will also be the possibility of civil unrest., consequent on food shortage and  continuing austerity.   

Maintaining public morale, is intricately linked to public mental health, and community engagement and involvement, and trust, is vital. The WHO has emphasised that the science alone will not beat the pandemic, and that authorities need courage and empathy, and that community participation will be critical in our ongoing public health efforts – the importance of community involvement will only be heighten in the event of a no deal Brexit.  We also need to maintain communication within the UK,  and internationally. Public health, NHS and care services need to be fully involved in Local Resilience Partnerships.  

Professor Tim Lang highlighted the potential catastrophe ahead for food supplies in the short term. The UK is poorly prepared, totally reliant on private sector food retail supply and just-in-time supply chains.  Food poverty is rocketing. Food resilience is not seen as a government or collective problem but as a more individualised and ad hoc challenge for charity. Even without shortages, the fear of shortage and panic buying are a known possibility from this year’s COVID experience. UK food supplies are heavily reliant on the  EU.  Key foods likely to be disrupted are fruit and vegetables coming in and Welsh and Scottish lamb and beef going out. Under World Trade organisation rules, tariffs are automatically applied.  The average import tariffs  from the EU could be  20%. Welsh and Scottish lamb and beef could attract a 48% charge on export to the EU.     

In a no-deal, the immediate impact will be build up of trucks at Dover; a two minute delay to throughput quickly leads to a lorry queue of up to 7000 trucks, according to the “reasonable worst case scenario”.  

There are public health implications: air pollution and congestion, frustration, anger, local unrest and with sanitary provision only just being considered for truck drivers.   

Tim went on to describe a vision for an alternative vision for a post Brexit Britain, noting the continued absence of the much-delayed (English) National Food Strategy, now expected in early 2021.    

Gary McFarlane, Director for the Northern Ireland Chartered Institute of  Environmental Health described similar concerns for food, environmental and consumer safety. He feared a burgeoning workload for EHOs in local authorities , generally in response to COVID and then with added possible Crashout. Some EU systems are still central to for example, food safety. For example the EU RASFF system provided  vital early warning on  food  safety concerns. In a crashout scenario we could lose this and ist still unclear whether a viable replacement exists. Even as part of the EU food crime still goes on. The EU had not been able to stamp  out food crime, as exemplified by the ‘horsegate’ scandal,  but coming out of the EU  will make control of criminal activity even more difficult. CIEH was concerned that even within the EU inadequate progress had been made with regard to securing healthier diets, for human and planetary health. In the current emergency, CIEH was concerned for all aspects of environmental health control at all UK ports-extension of inspection times, congestion, increased air pollution and poor sanitary conditions.for truck drivers. The concerns that have been articulated in terms of delays at channel ports could/will also apply to ports like Holyhead and Liverpool where goods will move from GB to Ireland and Northern Ireland. And we must remember the potential consequences of no trade deal on the availability and price of food in Northern Ireland if it is coming from GB. CIEH would work with FPH to develop food standards to aim for Tim’s vision of an exemplary food policy for Britain. 

What can the Faculty of Public Health do?  

In the short term, the Faculty should advocate for, and reinforce the need for actions locally and regionally, funded and supported from central government. They could work with other public health bodies such as CIEH to amplify this message. 

Public health professionals at local authority and regional level should ensure Local  Resilience Forums have active public health involvement. The LRPs should incorporate food resilience planning in their emergency plans. Children’s Safeguarding Boards should also be mindful of the mental health needs of children,  the need to plan for local food insecurity and children’s food poverty and hunger and address it.   

LRPs need to be aware of the state of local public mental health, severely challenged in the COVID lockdowns. LRPS need to plan for more visible and widespread civil unrest in the light of a no-deal Brexit.  

Public health professionals should advocate for greater financial and service support  to local community groups, to enable enhanced mutual aid programmes to be delivered.   

In the longer term    

FPH should continue to advocate for a National Food Policy. This should promote sustainable diets as basis for food policy at all levels – linking nutrition to ecosystems, social and economic criteria. FPH should also support the https://www.sustainweb.org/news/oct20-future- british-standards-coalition-interim-report/.  

Leaving the EU creates an opportunity for public health experimentation, from which other countries can learn, and for attuning policy and law very closely to population needs in Scotland and Wales, where health is a devolved power. But the Internal Market Bill takes away this opportunity, and disrupts the UK’s devolved constitutional settlement in a way which it is difficult to challenge legally, given the way that the Supreme Court treats these constitutional rules. 

FPH will need to reactivate its lobbying to keep the UK as part of the European Centre for Disease Control and Surveillance ECDC and other European  public health institutions like the European Monitoring Centre for Drugs and Drug Addiction EMCDDA, Lisbon.  Our government can pay the subs to rejoin. 

We will also need to see where we can judiciously test the  ‘Do no harm’ criteria  to future trade regulations– even if the lobby seems like it was from a different era.   

The legal implications for public health are in one sense the same as they have always been. Brexit is bad for the NHS and bad for public health. 

Brexit, in any form, is a form of major social change and transition and has, and will continue to have, major impacts on people’s lives and the wider determinants of health. Public health has a role in keeping health on the agenda at times of transition and at the heart of policy debates and implementation. It has never been more needed. 

Postscript   

Since our Webinar,  EU  negotiator  Michel Barnier has  been in London for a further round of talks;  there is speculation that Prime Minister  Johnson will  hold off any decision on a crashout Brexit until after the  US election; and a large scale national campaign, led by footballer Marcus Rashford to  provide free school meals  has received widespread local authority support– perhaps  providing the impetus fro local  food  distribution platforms of the kind envisaged by FPH. 

Written by

Professor John Middleton, Hon FFPH
President, Association of Schools of  Public Health in the European Region, (ASPHER)  john.middleton@aspher.org 
Immediate Past President,  UK Faculty of Public Health 

Professor  Maggie  Rae  
President, UK Faculty of  Public Health  
President@fph.org.uk  

With thanks to the presenters, Professor Tamara Hervey, Dr  May  Van Zwalwyck, Prof Tim Lang and Mr Gary McFarlane.  

Especial thanks  to the staff team at the UK Faculty of  Public Health who made it happen Mag Connolly, Keith Carter, David Parkinson and  James Gore.  

Thanks also to Paul  Lincoln and  Heather  Lodge, for  PETRA and  Dr Ibraheem Alghamdi for  helpful comments. 

This blog has been prepared for the SIG by Woody Caan, Liam Hughes and Lina Martino in response to World Mental Health Day on 10th October 2020, which emphasized the importance of advocacy for mental health in the era of Covid-19. The Faculty has had a good track record in recent years for supporting public mental health, and recognizing the interactions between mental and physical health in the spirit of “Equally Well”. It is encouraged to tackle Covid-19 through advocacy for integrated policies and better resources for mental health as an integral part of the proposed national investments to fight the pandemic.

Covid-19 has had a deep impact on individuals, families and communities, and on health professionals and their front-line colleagues in all parts of the U.K. As more has been learned about the disease, it has become more apparent that it has generated major mental health issues, and that these are likely to continue for many more months. Some examples are given below:

• Inpatients have experienced major trauma, with associated mental health symptoms (such as cognitive disruption, anxiety and depression, and for some PTSD) which extend well beyond discharge.
  
• Those living in the community with mild symptoms of Covid-19 may experience a “long tail” of reported physical and psychological symptoms including respiratory damage and renal failure, fatigue and muscle soreness, and cognitive impairment and “mind fog”. Often, they report that clinicians do not seem to take their reports seriously.
  
• Bereavement is an issue for relatives, friends and the wider community, especially given the constraints of social isolation, and there is good evidence about what can be done to help, at pace and scale (and at low cost).
  
• Suicide rates are likely to rise as social uncertainty intensifies, unemployment increases and social protection is scaled back.
  
• There are reports of rising mental health pressures on children and adolescents as they return to school, concern that the diversion of health visitors and school nurses into hospital roles will leave schools and community teams under-resourced, and reports of the delayed return of SEND pupils with complex needs.
  
  The pandemic has exacerbated long-standing health inequalities, including in mental health and wellbeing. A national survey by Mind revealed that existing inequalities in housing, employment, finances and other issues have had a greater impact on people from Black, Asian & Minority Ethnic (BAME) groups than on white people. The reduction in access to health and wider services due to control measures is also likely to have a disproportionate impact on BAME groups and people with severe mental illness.
  
  The concern of members of the Mental Health SIG is that the mental health dimensions of Covid-19 (and the associated resource requirements) may be missed by policymakers, planners and commissioners. Faculty members are encouraged to reflect on what they can do to reinforce the message that the fight against Covid-19 requires attention to mental as well as physical health.
  
  Resources on Covid-19 and mental health, including guidance on public and workforce wellbeing, can be found on the SIG’s web page: https://www.fph.org.uk/policy-campaigns/special-interest-groups/special-interest-groups-list/public-mental-health-special-interest-group/mental-health-and-covid-19/

Woody Caan, Liam Hughes and Lina Martino
FPH Mental Health SIG