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Posts Tagged ‘Food’

Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners.  Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost.  Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the   hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are.  Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base.  But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery.  This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

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By Alan Maryon-Davis

Health Secretary Andrew Lansley wants to encourage people to eat healthily, drink sensibly, stop smoking and get more active without lecturing or hectoring them. People don’t like being told what to do or not do – least of all by the Government – so Lansley says we should provide them with information and incentives and let them choose for themselves – nudging rather than nannying. Hence the Great Change4Life Swapathon with its supermarket discount vouchers for healthy options. Lots of carrots, no sticks.

There’s also much nudging behind Lansley’s Responsibility Deal with the food, drink and fitness industries. Double nudging – Lansley nudging them to nudge the public. Industry will “pledge” to provide information and incentives encouraging healthier choices.

So where’s the fudge? In return for industry cooperation (and cash) Lansley has said he’ll go easy on mandatory regulations around such things as marketing, labelling, availability and pricing. To be fair, he doesn’t rule these threats out completely. He talks about the Nuffield Ladder of Interventions, with the least intrusive (information, education and incentives) at the bottom and the most intrusive (regulation and legislation) at the top. But he’s made it clear he doesn’t want to climb that ladder unless he absolutely has to. It wouldn’t fit his political philosophy.

So there’s a big fudge around how he’ll monitor adherence to voluntary approaches, assess progress and judge when to bring in mandatory controls. The food and drink industries are notoriously slippery, evasive and foot-dragging – just look at labelling and marketing. Meanwhile the health lobby is going along with the Responsibility Deal in the hope that things might be different this time – well aware they risk being be-smudged as part of the fudge.

I’d like to see a solid pledge by the Government to regulate or legislate if voluntary approaches fail and to be crystal clear about how and when such judgements will be made. Without an explicit commitment to use force if necessary, the deal will be seen as no more than a charade letting Big Business off the hook.

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The Faculty of Public Health today publishes our joint manifesto on public health, alongside the Royal Society of Public Health. 12 Steps to Better Public Health offers a dozen practical recommendations that, if adopted by the next government, will improve the UK’s health and well-being for the new decade.

The joint public health manifesto calls for:

  1. A minimum price of 50p per unit of alcohol sold
  2. No junk food advertising in pre-watershed television
  3. Ban smoking in cars with children
  4. Chlamydia screening for university and college freshers
  5. 20 mph limit in built up areas
  6. A dedicated school nurse for every secondary school
  7. 25% increase in cycle lanes and cycle racks by 2015
  8. Compulsory and standardised front-of-pack labelling for all pre-packaged food
  9. Olympic legacy to include commitment to expand and upgrade school sports facilities and playing fields across the UK
  10. Introduce presumed consent for organ donation
  11. Free school meals for all children under 16
  12. Stop the use of transfats

The full manifesto is available to read here, and the front-page Guardian story, with an accompanying podcast from our President Alan Maryon-Davis, is available to read here.

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Eating ourselves sick

Our economy is geared towards making us sick, according to speakers at the Big Food Debate in Liverpool.  The roots lie in the war and post-war years when the population was urged to eat more meat, butter and sugar and the farming industry was supported to grow, grow and grow.   

Academics in nutrition, public health and food industry professionals  met here to discuss what was wrong with our current food production and consumption.    

There have been two major messages to take away.

  1. Robin Ireland, Heart of Mersey chief executive argued that food campaigners have to learn from the anti-smoking lobby and push for national reforms like the smoke-free legislation or the vote last week to ban point-of-sale displays and vending machines.
  2. Professor Philip James, International Obesity Task Force Chair, felt obesity was akin to climate change.  Responsibility could not be put on the individual alone, that was just not enough anymore.  We needed to change our toxic environment – food chain, transport infrastructure, urban design, animal and agriculture industry – through wholesale strategic measures.

We clearly need to create a new food chain that benefits people, not just the food industry.  Too much to ask?   Not really, according to Professor Simon Capewell (Professor of Clinical Epidemiology at Liverpool University and Chair of FPH Cardiovascular Committee) who pointed out that the UK is lagging behind other countries and asked why we cannot use legislation to ban the stuff in our food that’s making us so sick – trans fats, salt and saturated fats.  However, Professor Jack Winkler (Director of Nutrition Policy Unit at London Metropolitan University) argued for incremental changes.  He called the FSA’s salt reduction policy the single most successful nutrition policy since the Second World War, exactly because it has been so unobstrusive and incremental.  Professor Philip James said it was necessary to work with the food industry because they had the power to transform the food we choose to eat  

Whatever the view, more must be done or we have a very real obesity epidemic in our hands; not to mention climate chaos because the way in which food is produced and consumed is inextricably linked with the environment. 

Amidst the doom and gloom were positive examples: take the Netherlands which has redesigned its cities to enable easy cycling and walking, transforming the health profile of its population.  In the Caribbean, obesity (and public health) is recognised as a cross-government responsibility, not just one for the health ministry. 

But some englightened  initiatives were to be found closer to home.  Last night at a lovely Italian restaurant in Liverpool’s Albert Dock, we were amazed to find a healthy eating guide attached to the menu, showing the dishes that are good energy boosters, the ones perfect for your daily dose of vitamins and so on.  And this morning, at our hotel, there was a menu card explaining the ‘superfood’ options available at the breakfast buffet.  We’d certainly never seen anything like it in London (apart from in an organic juice cafe perhaps…).   

But as it stands, we’re eating ourselves sick and while we’re at it, devouring the health of the planet as well.

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