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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.

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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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by Professor Allyson Pollock, professor of public health research and policy at Queen Mary, University of London

The Health and Social Care Bill 2011 represents the biggest threat to public health for 60 years and it is time for the public health community to stand up and say so.

Deliberately conceived as an ‘Abdication and Abolition Bill’, the proposed legislation would sever the duty of the Secretary of State to secure and provide comprehensive healthcare throughout England.

Entitlements to health care are to be abandoned in order that a consumer market can be substituted for a needs-based system and, in David Cameron’s words, the NHS turned into a “fantastic business for Britain”.

As these briefings to the House of Lords show, the Bill will destroy the public health foundations of comprehensive healthcare and the ability to gather information and monitor inequalities.

Geographic administrative units – the hallmarks of the NHS – are to be abolished. Whilst commissioner populations will be made up from GP registrations, GP boundaries are being dissolved.  Patient enrolment and disenrollment will lead to unstable denominators and render fair service allocation and planning impossible.

No-one will have ultimate responsibility for ensuring everybody in a geographic area gets access to a GP. Above all, the ability to monitor equity of access within a comprehensive system will be undermined by lack of data and local variations in entitlement.

Public health will be shunted out to local authorities but the resources, functions and services that will go with it are not defined.  It is even impossible to tell the populations for which it will be responsible.

Local authorities and clinical commissioning groups will have enormous freedom to decide what they will and won’t provide and the boundaries between chargeable and non-chargeable services will be blurred and subject to local eligibility criteria.

In place of equity will be service and patient selection by commissioners and service providers intent on managing the financial risks of the marketplace.  Commissioners will be allowed to outsource their functions to healthcare companies that specialize in these techniques.

The marketisation of healthcare will lead to the denial of care on a scale not seen in England since pre-war days.

At a minimum the Bill must be amended so as to restore all the Secretary of State’s duties and functions and the structures of a national public health service.

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by Dr Geraint Lewis

For the past eight years, I have had the sometimes-dubious pleasure of living in London’s King’s Cross neighbourhood.  Being so close to the centre of the city, I do my best to cycle as often as I can around town. However, my repertoire of safe cycle routes is rather limited, and I dread straying too far away from my familiar routes and ending up somewhere where I have to battle my way home through the frenzied London traffic. The result is that I cycle less often, and less far than I would like to.

To be fair, these days there is a wealth of websites and apps that could help me navigate safely around London by bike.  The trouble, though, is that the safe bike routes themselves are just too complicated.

Take an example. Let’s say I wanted to cycle from my home in King’s Cross to St. Thomas’s hospital near Waterloo.  Although I know the walking route I would take to get there, I have no idea how reach the hospital safely by bike.  Go to the Transport for London  (TfL) website and it suggests a route that involves no fewer than 57 stages—as compared with two stages for the same journey by tube (Piccadilly line to Leicester Square, then the Northern line to Waterloo).

Indeed, London’s cycle network is so complicated that TfL appears incapable of displaying it as a complete map on its website.  Instead cyclists must order 14 paper maps to cover the whole city, plus a separate PDF for each of the new cycle superhighways that are currently being built.  Even where individuals have gallantly tried to produce simplified bike maps of London, the end result still bears too much resemblance to a plate of spaghetti.

Other cities have had a go at creating much simpler cycle maps aimed at encouraging more people to cycle. In Edinburgh, for example, Mark Sydenham and Martin Baillie have developed a tube map for bikes.  But the reality is that Londoners, like the citizens of many large cities, actually use the public transport network as their “mental map” for getting around their city.

The idea that Tim Miller and I suggested is that planners should build a bike network that recreates this mental map we are all so familiar with.  London’s bike network would directly resemble the tube map; Newcastle’s would follow the metro map, and so on.  In the jargon, what we are calling for are cycle networks that are “homeomorphic” or “topologically equivalent” to their public transport network. So in London, the cycle network we would like to see built would join up every tube station using analogous bike lanes to the tube lines – sharing the same names, colour codes and destinations as the tube lines.

So in this new world, my journey from King’s Cross to St. Thomas’s would simply involve taking the “Piccadilly bike lane” to Leicester Square, and turning left to go down the “Northern bike lane” to Waterloo.

What would be the costs and benefits of this proposal? Clearly, to build a network of safe cycle routes would take a large, sustained investment.  It would require building tens of kilometres of off-road bike lanes and closing off a considerable number of streets to through vehicular traffic.

However, the London tube map is a fixed asset that will be with us for generations to come, so this expenditure should be viewed as a very long-term investment. Just as with the tube network’s 150 year history, we would need to start small and build up the cycle network slowly, bike lane by bike lane and tube stop by tube stop.

From a public health perspective, I suspect the benefits of this proposed scheme would be at least fivefold.  First, it would encourage more people, including visitors to the city, to make longer journeys across town because they would now have more confidence that they could get to where they were going and be able to find their way back in one piece.  Second, it could reduce fatalities if more cyclists used off-road cycle lanes and quiet roads that had been closed to through vehicular traffic.

Third, it would reduce the city’s carbon footprint. Fourth, it would encourage cross-modal journeys because the cycle network and the rail network would now be inextricably linked. But finally, and rather sneakily, we might be able to increase journey distances from point A to point B by designing cycle routes between tube stations that were slightly more circuitous than were strictly necessary.

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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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Parallel Session A (c) at the Faculty of Public Health annual conference, Wednesday 7 July.

Chaired by Rachael Jolley (FPH) and with panel members Chris Bentley (Head of Health Inequalities NST, Department of Health), Peter Kellner (President, YouGov), Samantha Callan (Chairman of Residence, Centre for Social Justice).

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Plenary Session 4 at the Faculty of Public Health annual conference, Wednesday 7 July.

Chaired by Adam Brimelow (BBC Health Correspondent) and panel members Prof. Julian Le Grand (LSE and former No 10 health advisor), Anna Coote (Head of Social Policy, new economics foundation), Dr Anna Dixon (Director of Policy, King’s Fund) and Dr Paul Edmonson-Jones (Director of Public Health and Primary Care, Portsmouth City Teaching PCT).

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