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  • Andy Graham – specialty registrar in Public Health, County Durham

A couple of years ago I found myself in need of a dissertation topic for an MSc in Public Health – ‘make sure it’s something you are interested in’ was the advice. Simple I thought, I just need to weave football and beer into a research project! All joking aside though, I have become interested in the relationship between the two over the years.

As a public health professional and former A&E nurse, I am well aware of the potential harms of excessive alcohol consumption. Also, as a fan who both attends matches and watches on TV, I have become increasingly aware at how visible this relationship has become. Of course, football and beer have long been associated, ever since Victorian landlords would set up teams, use the land out back for a pitch and, in the amateur days, employ the team as barmen in lieu of pay.

But at the risk of sounding like my dad, when I ‘was a lad’, you either went to the match, where as a young working class man it was normal to have a pint with the lads, or you waited for Saturday night’s Match of the Day for your football fix. The pubs were open sporadically, had no TVs, and the football was rarely broadcast anyway.

Fast forward a few years and we have football on satellite TV almost every night of the week and all day at weekends, most top flight football clubs sponsored at some level by an alcohol brand, marketing of alcohol, beer in particular, is rife and the norm appears to be drink beer and watch football with the lads in the pub. Opportunities to do both are far more common than when ‘I was a lad’, and not just within pubs, but within living rooms, where the cheaper alcohol deals of the supermarkets are very popular. As a dad myself I was disturbed by these developments, but hadn’t been able to quantify them.

I decided my dissertation would try to measure the amount of alcohol marketing that football TV viewers were exposed to. With the help of Jean Adams at Newcastle University, I planned the research. I chose six live broadcasts representing over 18 hours of footage, developed coding frameworks and watched 40 hours plus of coding footage to consider all the verbal and visual references.

The results shocked me:

• Over 2,000 visual images, 111 per hour on average, or around 2 per minute.

• 32 verbal references.

• 17 traditional advertisements, accounting for 1% broadcast time.

• Over 1,100 visual images in one alcohol sponsored Cup competition alone

The issue of traditional advertising commercials is interesting because the ‘voluntary’ codes of practice in place to regulate how alcohol is portrayed (should not appeal to youth, should not suggest social success, etc.) are most relevant to this type of advertising. Given that we know that quantity of alcohol marketing is more important than content, then the apparently unchecked stream of visual references in this research may be even more important, and we could argue that the current controls are completely inadequate because they are focused on content, rather than quantity.

I can’t help but feel that we have taken our eye off the ball – the globalisation of sports such as premier league football as a product, the satellite age, the endless thirst for profit and market share within corporations, the ‘self’ regulation that fails to control the exposure reported above, the relaxed licensing laws in this country, and the increase in type, availability, and affordability of alcohol. All of these things create a perfect storm in which alcohol and sporting idols become normalised as one and the same, and the brand becomes a member of the team. It feels as though the relationship between sport and alcohol has evolved towards its perfect and logical form.

I am disturbed to be one of a generation of football fans that has been manipulated in this way and that my children are also targets. And meanwhile, the alcohol industry has a seat at the policy making table through the Public Health Responsibility Deal. So we must ask the question: are we sleepwalking into a situation where drinking alcohol is so closely associated with the sporting heroes that children see on TV, that they are being actively normalised to become drinkers? No one seems to question this, but it is time someone did, and through public health advocacy it may just be up to us.

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  • by Baroness Kinnock of Holyhead

This article was originally published in the December 2013 issue of Public Health Today, FPH’s members’ magazine. It is reproduced here to mark World Water Day tomorrow, 22 March 2014.

When, in 2007, readers of the British Medical Journal were polled to discover what they believed to be the greatest medical advance since 1840, many people were surprised that they chose ‘sanitation’.

They shouldn’t have been. History emphatically demonstrates that clean water, functioning sewers and public hygiene are basic to health and wellbeing. That truth is plain – but may be so simple that it invites complacency.

In 1854, when Dr John Snow recognised the connection between a communal hand pump on Broad Street in Soho and a raging cholera epidemic, he isolated the pump, saved countless lives, helped to found the new science of epidemiology and swept aside the previous conventions that attributed cholera and several other diseases to ‘foul air’. The implications of this breakthrough seized the whole of society. The rich and powerful were almost as grievously affected by filth-generated disease as slum dwellers.

In addition, the economic benefits of protecting the workforce against a mass killer like cholera were evident even to those usually reluctant to support improvements in living conditions. Public investment in sewers, water filtration and chlorination became prodigious and rapid. Victorian civic modernisers, engineers and entrepreneurs laid a sewerage system through most of urbanised Britain, much of which is still in use today.

Progress on a proportionately huge scale and at rapid pace is needed now in large parts of the world. For at least 2.6 billion people in the ‘developing’ world lack of sanitation is the prime cause of ill-health and premature death, especially among under-fives.Great improvements have been secured since the 1980s when cholera killed an estimated three million people a year globally – but the annual mortality level is still around 100,000.

Incompetence or malice can have devastating effects. In Zimbabwe, Mugabe’s government took funds away from water treatment plants and refused replacement international aid until the cholera crisis became acute. In South Africa, privatisation of water programmes resulted in disease for the poor who couldn’t afford clean water, but not for the relatively prosperous who could.

The economic and social penalties of bad or non-existent sanitation are monstrous and the advantages of good sanitation huge. The World Bank has calculated that for every £1 spent on sanitation, £3 is returned in increased productivity. The association between cleanliness and Godliness is not proven. The link between hygiene and efficiency is.

However, the compelling evidence for the multiple benefits of good sanitation is still not enough to attract the high priority it deserves. Lack of money, pressure to pursue other objectives, packed and expanding cities, industrialisation and desperate water shortages all impede improvement. But these challenges must not be allowed to stall progress.

Let those who decide policies and funding make just one visit to a place where a two-year old girl is dying in agony and exhaustion from diarrhoea that could have been prevented if her district had access to clean water and a safe means of disposing of sewage. I have seen too much of such avoidable tragedy. It’s why I plead for more reporting, recognition and determination to cure this scourge by stopping its cause.

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  • by Dr Anne Eyre
  • Trauma Training

I recently met a Director of Public Health. We were both in the lunch queue at a conference which was focusing on civil contingencies, the needs of people in disasters and organisational structures for addressing local resilience.

As we queued I asked her about provision of psychological (trauma) support services in her area for addressing the needs of people in the event of a major emergency. She replied, somewhat curtly, that she did not know: it was not her responsibility she said; it was not her budget. I was told I obviously hadn’t read the Health and Social Care Act, 2012.

Somewhat bemused, I sought reassurance. Perhaps I had misunderstood; she was not suggesting that psychological support services are not to do with public health? Sadly, I did not get that reassurance.

Just to be clear I went away and re-read the Act, and also the Department of Health’s guidance on the roles and responsibilities of Directors of Public Health in Local Government. This says that, among other things, Directors of Public Health (DPH) should offer leadership, expertise and advice on a range of issues, from emergency preparedness through to improving local people’s health and concerns around access to health services.

With regard to health emergency, preparedness resilience and response (EPRR) the role of Local Authorities, via their DPH, is to:

  • Provide leadership for the public health system within their local authority area;
  • Take steps to ensure that plans are in place to protect the health of their populations, and
  • Fulfill the responsibilities of a Category 1 responder under the Civil Contingencies Act.

This is encapsulated in the Emergency Preparedness Framework 2013 (NHS Commissioning Board, 2013).

At a time of tight budgetary constraint, and pressures on all those working within our public services, keeping trauma support and other mental health services on the agenda remains a formidable challenge in ordinary time, let alone in the context of major emergencies and disasters.

Perhaps this helps to explain why psychological support services, and indeed broader aspects of humanitarian assistance, remain the poor relation when it comes to emergency planning, response and longer term recovery in so many areas of the country. But these are integral aspects of public health, and not just in the event of disasters.

It is a worrying thought that our sense of health responsibility could become limited only to those activities over which we have direct budgetary control. Directors of Public Health in particular have a key role to play in delivering real improvements in local health in today’s health system. They are corporately and professionally accountable; with such seniority comes responsibility.

The challenge and expectation on all those who lead on health-related initiatives before, during and after emergencies, is that they will think holistically about people, across phases of disaster, beyond rigid organisational structures and within a multiagency framework in responding to the needs of their communities. For a long time this idea has been encapsulated in the concept of integrated emergency management and it is integral to so many of our organisational philosophies today.

I think it is important that we never forget that public health is about people and that responding to disasters – before, during and after they strike – is about helping and supporting people, including through the provision of robust public mental health services. This is not to say it is easy, and not to acknowledge that addressing mental health and other needs in today’s world of limited budgets and organisational structures can be difficult. However the challenge to those in leadership positions, and indeed all of us, is to work with and through these, not be constrained by them.

The public and those we serve will help ground us in this. Try telling those affected by the recent floods, or any other disaster for that matter, that public health in emergencies is not to do with psychological support.

References

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

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

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

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

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

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

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

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

Image

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

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

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

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

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

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

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

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  • by Lucy Smith

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

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

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

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

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

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

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

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

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

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

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

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

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

Feedback about Brixton Reel:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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by Professor John Ashton, County Medical Officer and Director of Public Health for Cumbria

In one of his brilliant short films in the 1960’s, Ingmar Bergman depicts an extravagantly dressed clown, rolling into a small Swedish town, amusing all the children with circus tricks as he passes through. He then goes on to call at a house where he carries out a murder, changes into everyday clothes and strolls out of town unnoticed.

Over the past few weeks, as the scale of Jimmy Savile’s alleged abuse continues to grow, I can’t help but be reminded of Bergman’s character’s wicked genius.

The enormity of Savile’s alleged crimes spanning four decades would seem to be equalled only by the failure of safeguarding and governance at a range of institutions.The apparent breakdown in those systems now extends well beyond the BBC to include local authority adult and children’s social services, the NHS and the media and press who we look to to expose crime and matters of public interest.

But the real lessons of the Savile affair go much wider. They extend to weaknesses in our democratic institutions and processes where powerful men sitting on the top of bureaucratic hierarchies are all too often themselves the product of closed institutions of one kind or another. They lack a 360 degree moral and social compass. This is compounded by systems that we have developed based on over-dependence on professionals and technico-managerial, box-ticking exercises. These systems are not fit for purpose and fail those very people – the young, the frail, the vulnerable – who they are supposed to guard and protect.

If there is to be any kind of a positive side to this major tragedy of epic proportions it is that it has revealed the bankruptcy of our attitude and arrangements to safeguarding the most vulnerable among us to whom we all have a duty of care. It does take a village to raise a child.  We are all our children’s keepers.  If social workers have claimed territory that they are unable to occupy fully we have all colluded in a hideously flawed paradigm.

What is missing is a systematic, three strand, public health approach built on the secure foundations of full public engagement and  involvement rather than an abdication to a small but dedicated cadre of professionals.  Civic society has been squeezed by the professionalisation of everyday life coupled with the growth of an overpowering obsession with individualism and consumerism.  We have all become bystanders watching and waiting for somebody else to intervene.This has to change if we are serious about safeguarding.The voice of the child must be paramount and we all need to listen and act,  not just those paid to do so.

Secondly, the dysfunctional relationships between agencies has to change. Joining up the dots is impossible if front line workers don’t talk to each other. And thirdly those who have safeguarding in their job description must accept their wider responsibility to share it with the whole community. Whether they be social workers, clinicians, teachers, police or professional groups, these professionals need to be accessible and responsive when their unique skills and powers need to be deployed. Safeguarding must move upstream into prevention, into tackling abusogenic environments and into preparing the vulnerable and at risk to be able to speak out.

Yes, bureaucratic tick box arrangements do have their place. We are entitled to ask: who was ‘It’ for safeguarding on the BBC Board and in each of the NHS, Local Authority and other bodies where Savile was apparently able to prey unchallenged?

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