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Drug related deaths: getting some fundamentals right

August 15, 2019 in ADPH Updates, President's Blog by admin

ADPH Vice-President Prof Jim McManus argues for the importance of getting the fundamentals right when it comes to tackling the complex issue of drug-related deaths

Today the Office for National Statistics published the latest figures on drug related deaths. And we have seen an increase. In particular, on top of the news about accidental poisoning a couple of weeks ago, we have cause for concern.

But as usual with this topic people will seize on it to provide easy solutions to what is a complex problem. So let’s bust some myths before we get down to the fundamentals we need to get right to stop people dying.

Myth 1: It’s all down to the changes in commissioning in England

This is simply not true. Scotland has had no changes in commissioning of drug treatment and has seen numbers of deaths rise far beyond England rates, and continue to rise, year on year. Similarly, the rise in England started in 2011, well before transfer of responsibility.

A major national review of drug related deaths concluded there were multiple factors including the age, immune system and respiratory health of some cohorts of opiate and opioid users, access to a range of treatment including NHS treatment and supply of drugs. We also know overdosing becomes more likely if your treatment is not properly calibrated and you use drugs on top of what is prescribed.

This is not about who commissions drug treatment. It is about how we ensure people get into the right services for their needs. And this means clear pathways for drug treatment needs, and for other needs like physical health, mental health and housing.

Myth 2: There is no residential rehabilitation left

Despite the efforts of one or two for-profit companies including UKAT (UK Addiction Treatment Centres) to convince us that this is all down to residential rehabilitation placements, this simply isn’t true.

First, the Scottish and English experience have both seen significant rises in drug-related deaths so the attempt to claim a move away from residential rehabilitation centres is the cause simply does not stack up.

Second, no amount of residential rehabilitation will treat people who need lung or chest treatment because of long term respiratory suppression from smoking and opiate use, plus multiple other conditions. In and of itself this is not the solution.

The examples of service innovation in the 2017 Collective Voice report demonstrate more appropriate approaches to preventing and managing overdoses than an approach based primarily on residential rehabilitation. One clearly effective intervention is ensuring Naloxone is available for appropriate use – this will save lives.

We know residential rehabilitation doesn’t work for everyone. For some it works well as part of a pathway of care. But it isn’t, never was, and never will be the main way we need to address this public health challenge.

Does that mean nothing can work?

No, there are things which can work. But in order to get to them we need to set aside the self-interested myths put about by people who stand to profit from them while the issues remain unaddressed. I mentioned above the Collective Voices approach, which collected a range of innovation from various places in reducing drug related deaths. Some of these are being adopted elsewhere. Some of these tools and methods are slow to roll out.

We can reduce drug-related deaths, but there are two vital ingredients we need. The first is proper funding – this is an area that has experienced severe cuts over the last 11 years (see Commissioning Impact on Drug Treatment report and Drug and Alcohol Services in Scotland publication). And the second is for public health commissioned services and NHS commissioned services to work together – integration is the way we will succeed.

So what should be done?

Here are my key steps:

  1. Identify the populations at highest risk – we do know mostly who they are, and we will typically find they have multiple needs , many are ageing, many have suppressed immune and respiratory systems and they are vulnerable for a number of reasons including housing and social support
  2. Ensure they all have good primary care which understands the complexity of their needs and ensures they can access services appropriately
  3. Ensure they get good quality drugs treatment
  4. Get every commissioner and provider together and build a pathway around this population, with a range of treatment. Specific lung and chest health, for example, needs to be included in this. So does housing
  5. Continue to make Naloxone more available and more usable
  6. Ensure clear joined up pathways from custody into the community. NHS England has often been conspicuous by its absence and people have often been discharged from prison without clear links into community services or given Naloxone. This is failing them.
  7. A national review of what works and roll out of evidence-based practice and innovation where we don’t know what works best
  8. A national strategy for drugs and one for alcohol which focus on saving lives and keeping people healthy.

This needs funding, and both the cuts in public health funding and the lack of anything about drugs in the NHS Long Term Plan should give us major cause for concern.

Drug treatment remains almost absent from the heath policy debate. While the NHS Long Term plan suggested a greater say in commissioning of sexual health, it was telling it didn’t mention drug treatment. It was telling that the Green Paper on prevention mentioned sexual health, but didn’t mention drugs. This is not policy which is focused on burden of disease to people and society. If it was, we’d have drugs higher up the agenda.

People who use drugs and who have complex needs as a result are still fellow-citizens whatever some may think of them. They have rights, and the NHS constitution applies every bit as much to them as it does to anyone else. Intervening effectively will save lives.

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We need to rebuild our social fabric

August 5, 2019 in ADPH Updates, President's Blog by admin

ADPH President Dr Jeanelle de Gruchy and Charlotte Augst, Chief Executive, National Voices look at what the recently published Green Paper means for patients and the VCSE.

We have got far too used to Brexit drowning out work on the key issues that really affect the wellbeing of our population. So much so, that it was a surprise for many when the Government managed to push out its consultation paper on prevention just before Theresa May left office.

The Green Paper contains many good proposals that are hard to argue with: making Britain smoke free by 2030 and halving childhood obesity by the same year, are goals that would have a significant impact on people’s lives if they were achieved. We also welcome the ambitious target of adding five healthy years to people’s life expectancy. This commitment offers the opportunity for bold action to make health and wellbeing a cross-government priority, like in Wales and New Zealand.

However, there is an overall lack of ambition and little to offer in terms of how these goals can be delivered. The paper gets carried away with its own rhetoric on ‘targeted’ and ‘intelligent’ prevention (as if public health hasn’t always been a data driven practice, using scarce resources where they matter). It suggests genetic testing, apps and ‘lifestyle’ advice will make the difference and will be the main driver for change.

But – as local government and voluntary and community sector (VCSE) organisations, which support people to have better, healthier lives – we strongly believe that this way of thinking will lead to a dead end. Although some diseases are due to genetics, these play a much smaller role in shaping a person’s health than where they are born, grow up, live, work and age. It is simply not the case that poorer people are genetically different from their better off neighbours. Rather it is the unequal social, economic and environmental circumstances throughout people’s lifetime that contribute to widening health inequalities. This imbalance has only been made worse by the years of austerity and sustained cuts to local authority and VCSE provided services and interventions – including youth clubs, children’s centres, social care and much more.

The consultation paper says nothing about funding for such social infrastructure and little about the role of places and communities. This shows a lack of understanding of the things that good, healthy lives are made of and what is needed to rebuild the social fabric that enables us to thrive: attractive places that help us to connect to each other, advice and support when we encounter difficulties, activities that create relationships, purpose and resilience. A healthy society is not one that waits for people to become ill, but one that sees how health is shaped by social, cultural, political, economic, commercial and environmental factors, and acts on these.

As we enter another turbulent chapter of national politics, we are disappointed that we haven’t succeeded in landing these insights with enough policy makers on the national stage yet. But now is the moment to redouble our efforts. Locally, we will continue doing what we do best – enhancing wellbeing and creating social value. Nationally, we will continue to make the argument for investment in social infrastructure and services that benefit those whose lives are blighted by inequality, economic decline and lack of connection. This work hasn’t stopped, and neither will we.

Charlotte Augst, Chief Executive, National Voices and Jeanelle de Gruchy, President, Association of Directors of Public Health

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About National Voices
National Voices is the umbrella body bringing together health and care charities large and small in England. National Voices stands for people being in control of their health and care, through person-centred care. Its aim is for people to have as much control and influence as possible over decisions that affect their own health and care and to be partners in the design of services, research, innovation and improvement.

National Voices helps people and organisations to gain the knowledge, understanding, skills and confidence they need to engage more effectively and to make their approaches more person-centred. It has expertise in what matters to people relating to health and care, how to involve people, and how to work with the Voluntary Community and Social Enterprise sector.

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Taking collective responsibility for a healthier society

July 4, 2019 in ADPH Updates, President's Blog by admin

This is an adapted version of ADPH President Jeanelle de Gruchy’s speech in the conference plenary: ‘The future of care, health and wellbeing: opportunity, risk and ambition’ at the LGA Conference, July 2019.

As a junior doctor, I once saw a woman in my medical outpatient clinic with diabetes teetering on out of control. I spoke with her about the seriousness of the situation and about how she could better manage her diet to reduce her high blood sugar and avoid admission. After my clinic, I headed off to the local shop for lunch – where I met my patient, tucking into a large portion of fried chicken and chips.

It was vividly clear to me that it was unrealistic to expect people – even, or perhaps especially, at the point of imminent health crisis – to act differently on the basis of simple information and encouragement. Instead, what my patient probably needed over her lifetime was an environment – family, school, workplace, high street – that encouraged healthy eating and being physically active. And I could see this was true of so many more of the people I was seeing with major health problems.

This sense, that we needed to help people more effectively than the current system is set up to do, impelled me into public health as a discipline. Public health seeks to understand how we as a society create the conditions for people to develop diabetes in the first place – and then to help them manage their diabetes effectively to prevent it getting worse.

Public health in local government

Since moving from the NHS in 2013, public health teams are now firmly at home in local government – developing vital links across the council, the NHS and other local partners – with children’s and adults services, community safety, housing, planning and economic development, focused on addressing the social determinants of health.

This helps us work collectively with communities to create healthy, thriving places, to get people moving and connecting – for people to live a good life. This is the work that local government can and should be doing; it should be our ambition – and our strength.

Just as importantly, public health has maintained strong outcomes for the specific services we commission – drug and alcohol, sexual health, health visiting and school nursing, smoking cessation, physical activity and more. These are vital services and we’ve worked hard with the providers of these services to innovate and deliver improved outcomes despite government cuts to the public health grant of £850m in real terms.

The risk of further cuts to these preventative services is high – and the negative impact will be felt by other services, by our families and communities and will, of course, be expressed in our country’s health outcomes getting worse.

Challenging fatalistic thinking and championing prevention

We face some serious inequalities in health. Men and women living in deprived areas can expect to spend 19-20 fewer years in good health compared to those living in the least deprived areas.

By 2050, 1 in 4 of us will be over 65; between 1 in 2 or 1 in 3 will have a long-term limiting illness. This isn’t a good scenario for our society, or economy, or a sustainable public sector. But this is not inevitable. We don’t have to accept as fact an inexorable rise in poor health and ‘demand’. Because it’s not aging per se that’s driving demand, it’s unhealthy aging.

And we know that prevention works. Even dementia is not inevitable. The recent Lancet Commission on dementia identified nine modifiable risk factors across the life course which could prevent more than a third of dementia cases, including low educational level in childhood, obesity, smoking, social isolation, diabetes and physical activity. These all play to local government’s strengths, provided we’re effectively funded.

And we had great news this week about continuing drops in smoking prevalence, so we know we can do it. But the stats are not great for the other factors. Take physical activity – by the age of 75, only 1 in 10 men and 1 in 20 women are active enough for good health.

Taking responsibility for a healthier society

How are we organising ourselves as a society so that we end up with this grim statistic? This isn’t happening by accident. Our society is currently being socially and economically shaped to give us these poor results.

Our burgeoning epidemics of things like frailty, diabetes, heart diseases and cancers are not driven just by a lack of willpower – or ‘personal irresponsibility’, if you will – as if every succeeding generation since 1948 has worsened its diet because we’ve got progressively less good at self-discipline.

This is driven by a complex mix of social and environmental factors like poverty, access, advertising, food formulation, inactivity being the default option for many, and an assumption that the NHS will just fix whatever is wrong with us regardless of the cost.

Public health is about the art and science of improving our health and wellbeing through our organised efforts as a society – it’s not about blaming individuals for their so-called ‘lifestyle choices’.

It’s no good blaming and admonishing my patient with diabetes for going into the nearest chicken and chips shop if that’s their overwhelming, or cheapest, offer on the high street.

Everyone taking personal responsibility for their health has never worked as a population strategy. We know that policies which rely on people to know what’s required of them and do it, can lead to widening health inequalities.

The health and wellbeing problems we’re dealing with are complex societal issues, and they require approaches which work across systems. A simple single agency intervention is generally just not going to crack it. Whether it’s poverty, county lines and serious violence or domestic abuse, air quality, childhood obesity, unhealthy aging and increasing long term conditions… this is about people living and thriving in a place – it’s about good schooling, good homes and jobs, a decent income, it’s about community and connections, and sometimes health and care services.

Individualistic, silo thinking about services or ‘lifestyle’ takes the focus away from the socio-economic determinants of health, and detracts from the effective solutions we need to come up with.

We also need to shift to an approach that’s a positive one about people. Too often we refer to ‘system pressures’ or increasing demand or see our aging population or families with increasing needs as fundamentally the problem. Arguably, it’s we as public sector agencies who are creating the system pressures by not taking heed to do prevention effectively or develop a more fit for purpose system – or society in which people can thrive and grow old well.

The NHS Long Term Plan and Prevention Green Paper (which we hope to see in the next week or so) both herald the importance of prevention, and the latter, we hope, champions a focus on the wider determinants of health – and this is to be welcomed. This new dawning provides an exciting impetus and potential for a shift to a more sustainable population wellbeing focus.

Our ambition should be for a ‘Spending Review for Wellbeing’ which sets a test that every department puts wellbeing at the heart of its investment decisions (as is being done in New Zealand) and a sustainable funding package for local government and for public health. That’s why the ADPH supports the recent call by the Health Foundation and The King’s Fund for the Government to reverse £1bn of real-terms per head cuts to the public health grant.

We need to acknowledge that in 2019, your health and wellbeing is overwhelmingly dependent on who you are and where you live – this is unfair and drives inequalities. We need to challenge the way things are, maintaining a stubborn focus on prevention for the long term.

And I have an ask of local leaders – to recognise the role of the Director of Public Health with their knowledge of and responsibility for the health and wellbeing of their local population; their understanding of the evidence of what works for prevention, and their strong links across the council, the NHS, voluntary sector and many other partners in our local systems and places.

Our collective ambition should be a population wellbeing approach, with policies that create healthier places and fully funded, integrated and innovative services delivered in a place-based way.

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A spending review for wellbeing? An idea whose time has come

May 31, 2019 in ADPH Updates, President's Blog by admin

Guest blog by ADPH President Jeanelle de Gruchy for the Arthritis and Musculoskeletal Alliance

To its great credit, New Zealand has become the first country in the world to produce a “wellbeing budget” – a commitment to prioritise population wellbeing as the main mission of the government. A similar philosophy was adopted in Wales in 2015, with the Well-being of Future Generations Act requiring public bodies to think about the long-term impact of their policies on both people and places.

This is a bold and exciting approach for anyone living with a musculoskeletal condition or campaigning for change on their behalf – and for the wider public health community…

Click here to continue reading the rest of the blog on the Arthritis and Musculoskeletal Alliance website

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It takes a village to raise a child

May 28, 2019 in ADPH Updates, President's Blog by admin

Guest post by ADPH President Jeanelle de Gruchy for the NHS England blog

The National Medical Director for NHS England and Improvement and the President of the Association of Directors of Public Health discuss why prevention is key to the NHS Long Term Plan:

‘It takes a village to raise a child’ – this wonderful saying beautifully captures how an entire community of people must interact with children for them to experience and grow in a safe and healthy environment.

It encapsulates the interconnectedness of our society, across the generations and across all aspects of our lives.

If you think about it, it’s also true for us every stage of our lives….

Click here to continue reading the rest of the blog on the NHS England website

The lazy language of ‘lifestyles’ – let’s rid this from our talk about prevention

April 17, 2019 in ADPH Updates, President's Blog by Teresa Grandi

By Jeanelle de Gruchy, President ADPH

I’m writing this blog as I drink my flat white following my yoga class where the yoga teacher was wearing a fab ‘Carbs and cuddles’ sweatshirt; this is the life I think, this is my choice, this is my lifestyle.

I go out to my car and head for the motorway, annoyed that I will now have to sit for 40 minutes in traffic to my new office up north. Not really my choice I think, not really the lifestyle I want. Down south, I didn’t have to do that, I lived closer to work, and public transport was [subsidised] better. In one place I walk more and in another sit in a car in traffic more – same me, same motivation, different place, different behaviour. Environment and the choice landscape matters to how physically active I am. ‘Lifestyle’ doesn’t really explain it. So why do we keep using this word as if it explains everything about our health?

A number of years ago I read a blog that has stuck with me ever since – in 2015, Paul Lincoln wrote ‘Lifestyle: a plea to abandon this word in public health’ https://ukpublichealthnetwork.org.uk/lifestyle-a-plea-to-abandon-the-use-of-this-word-in-public-health/.  

In this strongly worded piece, Paul targeted the public health communities’ widespread and unquestioning use of the term ‘lifestyle’ and called for its use to be completely abandoned. His main argument was that its use frames public health at an individual level – ‘effectively blaming individuals for making irrational decisions that are detrimental to their health’.

The lazy language of lifestyle, and the lazy thinking behind it perpetuates a disproportionate focus on the individual over the range of behavioural, environmental and social determinants of health – and on individualistic solutions aimed at the individual just making different choices and changing their ‘unhealthy lifestyle’.

Apart from being ineffective, this framing of the problem, he argues, suits certain ideological viewpoints that tend to frame any counter view as nanny state-ism, and ‘helps industries that produce health-harming goods escape responsibility’. It also leads too easily to blaming those who don’t change their ‘lifestyles’ and are therefore responsible for their own early illness and death.

Paul asserted that continued use of ‘lifestyles’ was in fact ‘a harmful and unethical determinant of bad public health practice’, and should become anachronistic, especially given claims of a new narrative on prevention which demands a focus on the social determinants of health.

Unfortunately, ‘lifestyle’ has not become an anachronism. Unfortunately – and I would argue unacceptably – it’s still all too normal for public health professionals to uncritically use the term ‘lifestyles’. And despite the evidence, we continue to situate solutions in individuals and interventions to change their ‘lifestyle choices’.

The current use of ‘lifestyle’ has its origins in business marketing, a word capturing how to create desire and promote consumption. This isn’t done individually, but by using very sophisticated techniques targeting particular segments of society – groups of people, not individuals – selling cigarettes, alcohol, the best odds, Easter Eggs and fizzy drinks to make the world sing in perfect harmony. It’s a commercial determinant of health – and Paul Lincoln suggested the word ‘deathstyle’ would be more apt, given the way many of these commodities contribute to early death.

‘Lifestyle’ does two things – it puts emphasis on the individual, framing health-harming behaviour as individual choice so that secondly, it takes the focus away from the socio-economic determinants of health and from the health inequalities experienced by groups of people.

The Health Foundation and Frameworks Institute has been leading work to reframe the conversation on the social determinants of health – and I strongly recommend their Briefing to you (https://www.health.org.uk/thinking-differently-about-health ).

How we choose to frame things is critical, as the language we use, how we explain things and what we don’t say influences how people make sense of and engage with issues. They note that, ‘despite extensive evidence of the impact of social determinants on people’s health, public discourse and policy action is limited in acknowledging the role that societal factors such as housing, education, welfare and work play in shaping people’s long-term health’. It’s the differences in these factors that drive the profound inequalities in health outcomes.

Their research shows that the dominant way people conceptualise health is through models of individual choice and health care – and the solution is ‘raising awareness’ so people make different choices (and if they don’t, well then…) and the NHS. It’s not surprising therefore that the focus for policy makers is on individual-focused interventions and on the NHS.

They set out some preliminary steps to build support for the policies and programmes that will be much more effective in improving health and reducing health inequalities. The first one is: ‘Beware of gesturing to the importance of individual choice or responsibility’. I think we need to stop prioritising talk about ‘lifestyles’. 

Of course, there is another use of the term – the Urban Dictionary reminds me that many use the term for sex and sexuality – and that it wasn’t that long ago that a dominant discourse was about some people adopting a ‘gay lifestyle’ to denote active choice and how that, so easily, led to victim-blaming. ‘Lifestyle’ was problematic then, it remains problematic now. What I like about this reminder of usage is that it shows the power of language – and how it can work insidiously and ideologically to maintain hegemonic power, the power of the ‘norm’, in this case of the heterosexual community. What I also like about this reminder is it shows how this power was challenged by citizens working collectively, using the language of human rights to deconstruct this dominant discourse and impacting positively on this inequality. Isn’t it time for us to do the same with the use of ‘lifestyles’ in health?

The new enthusiasm for prevention and population health are important opportunities for us as public health professionals to get our own thinking and language in order on what matters.

While I know a lot of us don’t like the emphasis on the individual, we do need to think through our role in continuing to privilege this problematic paradigm. We need to reframe our own narrative – which too often favours individualistic approaches – in order to more effectively influence priorities and plans. If we’re serious about preventing ill-health, reducing inequalities and improving health and wellbeing, we do need to focus on those things that will actually make a sustainable difference.

So the next time we cycle to work, nip out for sushi at lunch, sip on our cappuccinos and plan our pensions, let’s think through how we’re able to do this, and let’s talk about how we talk about those things that determine whether our lives are healthy or not. 

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Guest blog: A way forward on PrEP

March 1, 2019 in ADPH Updates, President's Blog by admin

by Professor Jim McManus, ADPH Vice President

As Scotland issues its report into the first year of PrEP for HIV, there is a fair amount of debate going on about where we are in England with PrEP. NHS England announced this week they wanted to roll out more places. I don’t know anyone who doesn’t want the further roll out of PrEP in England – the Local Government Association wants it, the ADPH wants it, community groups want it, even NHS England wants it.

But let’s be clear, this roll out creates an additional and unfunded £7m burden on councils’ sexual health budgets at a time when our budgets are being cut. That’s small change for NHS England. It’s a major problem for local authorities.

Despite NHS England’s press release yesterday[1] the issue of funding remains unresolved. It’s hugely welcome that NHS England will fund new places. However, clinicians tell me regularly, there is a double burden created by the PrEP Trial.

First, not all of the time and admin costs incurred by involvement with the trial are met by NHS England; “additional resources needed to help with data entry are not met by NHS England” said one clinician.

Second, the further associated costs of HIV tests and repeat GUM visits and other tests are paid for by councils through the public health budget. It’s no use saying people eligible for PrEP should be using GUM services more already, this trial is driving people into services (which is great) but creating a major financial burden we could easily solve.

And there is an easy answer. We even proposed it to government. Before Christmas, ADPH and LGA jointly called, with many sexual health and HIV charities, for the increased roll out of PrEP. At the time, ADPH said:

“PrEP is now even more affordable on the NHS. With the NHS saving substantial sums from the drug being cheaper as well as from fewer people needing treatment, we see no reason why NHS England should not extend the roll out of the trial to more people.

“While NHS England pays for the drug, local councils have to meet the costs of extra attendances and tests at sexual health services. These additional costs fall at a time when government is cutting public health budgets.

“The savings made by NHS England switching to generic Truvada would help cover the trial-associated service costs of extending recruitment to the PrEP trial and significantly reduce the burden on local authorities to support this important study.”[2]

The double burden created by the roll out of PrEP could be easily resolved by the Department of Health and Social Care (DHSC) or NHS England spending just 1% of the money DHSC has just found to bail out NHS Acute Trust deficits[3]. The money is clearly there and, in an era when we’re supposed to be moving to prevention, it is an odd policy choice not to find that money.

Getting the double benefit of rolling out PrEP and at the same time getting our residents into more frequent GUM checks would cost just £7m for DHSC or NHS England. That’s the opportunity.

What if we don’t? Well, we create £7m additional demand for sexual health services, and we either cut other public health services further to meet it or we end up with people being displaced from GUM services.

In other words, we end up with the danger of pitting one group experiencing inequalities against one or more others, while NHS England walks through the middle reaping the financial gains of generic Truvada and creating a needless fight between councils and local populations.

That can’t be good. I don’t blame councils for pointing this out. This is a clear example where we could easily work together as a system to solve a problem.

 

[1] https://www.england.nhs.uk/2019/02/prep-impact-trial-to-be-expanded/

[2] https://www.adph.org.uk/wp-content/uploads/2018/12/ADPH-PrEP-statement-Dec-2018.pdf

[3] https://www.hsj.co.uk/finance-and-efficiency/creative-accounting-behind-600m-dhsc-bailout-says-mp/7024456.article

The NHS Long Term Plan – let’s stop the ‘us and them’

January 18, 2019 in ADPH Updates, President's Blog by Lucy Sutton

The NHS Long Term Plan has finally arrived. There is much in the plan that Directors of Public Health would support: 

  • The shift in focus to primary and community services
  • Extra funding for those places with the greatest health inequalities
  • Training of medics on nutrition in all hospitals 
  • Action on air pollution within the NHS fleet 
  • Action on screening and vaccination inequalities 
  • £30M for rough sleeping initiatives 
  • Additional NHS gambling clinics 
  • Important focus on children and young people, cardiovascular disease, musculoskeletal disease, mental health and falls prevention.  
  • Alcohol care teams to be developed in collaboration with local authority commissioners. 

We welcome too the strong focus on smoking; but this, and in fact every commitment above, needs to be done in collaboration with LA commissioners.  

Our members are less welcoming of the doubling of the Diabetes Prevention Programme, and I’m sure could have found a more effective use of the £105m already invested in it. 

The press release on the NHS Plan’s commitments on alcohol and tobacco preceded the full plan by two days. We responded positively to this as they heralded the good intention for the NHS to do more to prevent modifiable factors damaging patient’s health. However, we waved three red flags of concern – the plans were ‘undeliverable’ without a good spending review settlement for public health; bold national policy change is needed to address the social determinants of health; and thirdly, the NHS needs the support and contribution of local authorities and the Director of Public Health to deliver the plans efficiently – we need to operate as a public health system.  

Cuts are the issue – more restructuring is not the solution 

But let me turn to some of the disappointing aspects of this plan. Imagine our surprise when the full NHS plan arrived the day after our welcome with the proposal to: ‘consider the potential for a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be.’ 

Unacceptably, ADPH was neither involved nor informed about the inclusion of a review of our commissioning responsibility – by NHSE, another public sector commissioner. At best this is a well-intentioned but extraordinarily ham-fisted effort to deal with public sector funding cuts – at worst, it is an unwelcome distraction from cross-sector collaboration to manage those cuts to ultimately improve citizen’s health and wellbeing. Cuts are the issue – restructuring is simply not the solution.  

Fighting among ourselves will deliver a worse outcome; how you do things does matter. So in that spirit, and for the NHS’ own good, we’re pushing back and saying there can be no review of the commissioning of public health services without the full involvement of Directors of Public Health. Reviewing what we do can be productive in illuminating areas for improvement – and we would support a review which looked at how public health services could be sustained and improved.  

I have raised our concerns with DHSC and have been reassured that they want to work closely with ADPH and public health stakeholders on this review. 

System challenges 

Austerity has been a major driver of change for over a decade. In part it has driven necessary transformation and efficiencies within public services; but for the most part, it has driven unnecessary demands on those services and arguably is now costing the government more than it is saving – as well as leading to all sorts of distortions within the public sector. Indeed problems which properly funded public health teams could prevent are now being displaced to the NHS, with avoidable extra cost. 

It was within this challenging context that public health moved from the NHS to local government in 2013. The case for the transfer of public health responsibilities remains unchanged – indeed we would argue, it is stronger than ever. Directors of Public Health are providing leadership and expertise to tackle the social determinants of health and deliver strong place-based population health approaches – as well as leading the transformation of those services we’re responsible for commissioning – substance misuse, sexual health, 0-19 year old’s health and wellbeing.  

There is much more to public health than the NHS – the Clean Air Strategy published this week has significant roles for local government and the Serious Violence Strategy advocates a public health approach. We need to challenge this default ‘NHS first’ logic if we are to build a truly preventative system. 

Public health commissioning has delivered improved outcomes 

The completely false presumption in the Long Term Plan is that council commissioning is delivering worse outcomes. This is simply not true. It is not borne out by outcomes data. There are several national reports that show local government has been successful in delivering services under difficult circumstances and has prioritised increasingly scarce resources effectively.  

We’ve brought new energy and rigour to the commissioning of these community services, often transforming who delivers them, where and how, making integration and partnership-working real – and, in the context of rising demand and huge cuts, largely delivering good outcomes. Redesign in many areas has focused on integration – integration with other public services, such as criminal justice, adult services, children and young people services; and integration across the wider health economy. It has also looked to commission the community and voluntary sectors and to increase social value through its contracts.  

‘Be careful what you wish for…’ 

When public health was in the NHS, we know that the funding for prevention was always on a shaky footing – there in good times, the first to go in difficult. This was also true of the funding of many non-acute, preventative community services, including those now commissioned by local government. As Jim McManus has blogged: ‘it was not better in the glory days’. We inherited long-standing challenges – from the underfunding of school nursing and fragmentation in health visiting, including poor links with GPs – to overly medicalised and expensive sexual health services, or drug services focused on clinical treatment and not yet recovery; and Directors of Public Health have worked hard to innovate and introduce new models to deliver improved outcomes for less. Local authorities have also taken some decisions that the NHS could not or would not make.  

In December 2018, our successful ADPH conference focused on ‘disruptive leadership’ – the kind of leadership that understands that improving outcomes often needs challenge and change, that isn’t afraid of challenging ‘the norm’ to enable innovation, and that knows how to be pragmatic and savvy while doing this. This is the kind of leadership that we so desperately need in the public sector – leadership to enable the reforms needed to better serve a population with changing needs and expectations.   

But commissioning can be a thankless task; with a focus on improving population outcomes with efficiency, it’s not often that providers thank commissioners for their efforts. It can lead to experienced professionals being asked to do things differently, or to change a service skill mix or integrate with other providers, or to change the location or mode of the service to make it more accessible for residents and patients. Often, the best innovation comes through commissioners and providers working in creative tension together – and there are very many examples of this leading to fantastic services.  

Joint commissioning of local health and care services in integrated care systems is becoming increasingly important to enable local government and the NHS to shape effective services – and indeed is already happening in many areas. 

It’s time to work as a system. With each part funded appropriately and sustainably. We will focus on articulating that. We all need to join together and end the unhelpful “us and them” discourse. 

 

 

by admin

200 Days On – My Reflections as ADPH President

December 6, 2018 in ADPH Updates, President's Blog by admin

 

(given as the introduction to the December 2018 ADPH annual conference)  

It’s 200 days today since I was inaugurated as President of the ADPH. Usually Presidents get asked what they’ve achieved in their first 100 days – but I’m proposing that, seeing as I’m a part-time President, my time gets doubled. So, time to see how we’re doing on the priorities I set out in May:

  • Challenging the norm and advocating for equality in all its forms
  • Developing a vibrant, member-led organisation
  • Promoting our unique local system leadership role
  • Ensuring we continue to be well-respected as an organisation – but with an ‘edge’ 

My first priority was to seek to highlight the insidious normalisation of injustice or structural inequalities related to some or other characteristic of who we are – our class, race, gender, disability. This normalisation of inequality in our society serves to protect the power of some groups over others, yet it is unjust and profoundly damaging to our health and wellbeing.  

When I spoke at my inauguration in May, the UN’s Special Rapporteur on racism had just published their report, which noted that racism in Britain was becoming ‘normal’ again. This week, analysis showed a record number of children are being excluded for racist bullying (The Guardian, 1 December 2018).  

And in November, we had the report of the UN’s Special Rapporteur on extreme poverty and human rights, which found that ‘for almost one in every two children to be poor in twenty-first century Britain is not just a disgrace, but a social calamity and an economic disaster, all rolled into one’. He noted that it was women and children and those most vulnerable who were being disproportionately impacted by recent tax and welfare reforms. The 49% real-term reduction in government funding from 2010/11 to 2017/18 was cited as a contributory factor, with people no longer having access to the vital services they needed. The UN’s Rapporteur’s view was that the UK government could end poverty if it wanted to. 

Many believe that austerity is now actually costing more to the UK government than it is saving, with the Rapporteur noting: ‘the many billions [taken from] the benefits system since 2010 have been offset by the additional resources required to fund emergency services by families and the community, by local government, by doctors and hospital accident and emergency centres, and even by the ever-shrinking and under-funded police force.’  

While the renewed focus on ‘prevention’ is welcome, the reality is that interventions to prevent poverty, poor outcomes and mental distress are being cut on a massive scale. And the money and focus continue to prioritise crisis management – rising A&E attendance, knife crime, suicide, homelessness.  

Increasingly, our members are shining a light on the negative impact that the changes in our public services are having on citizen’s health; this month the Guardian covered research commissioned by Alice Wiseman, DPH Gateshead, on the negative impact of the roll out of Universal Credit particularly on claimants with disabilities, mental illness and long-term health conditions, as well as homeless people, forces veterans and care leavers. The findings led Alice to make the damning comment that: ‘I consider universal credit, in the context of wider austerity, as a threat to the public’s health.’  

Our members have also been leading efforts to challenge the new cultural norms created in society by commercial interests, which perpetuate the concept that our major public health issues are down to a collective failure of individual willpower. In London, Danny Ruta, Steve Whiteman and Vicky Hobart have been key in the efforts to challenge what’s normal to impose on our children, with the ban on junk food ads across the Transport for London network; or Ruth Tennant’s work with ASH on reducing children’s exposure to smoking in their homes.   

Today, we are in the middle of the international 16 Days campaign to end violence against women and girls. The ability of those in power to maintain their positions through normalisation and victim-blaming is no better demonstrated than by this form of violence and control. We kick-started our ADPH policy work on violence (in all its forms) through a lively conversation at the ADPH Council in October – and hope many of you will be engaged as it evolves.  

And finally, I recently had a fantastically positive challenge to my own preconceptions of what’s normal, when Becky Rich, a Dance Leader and Ambassador for DanceSyndrome (http://dancesyndrome.co.uk/) – a dancer-led, disability-inspired organisation – spoke about her many years managing her heart condition, how she had lost 3 stone through dance and healthy eating, and how she wanted to support others to do the same. I celebrate Becky who inspires us all to challenge the norms that limit us from living our lives fully. 

  Becky Rich #dancer #activist 

My second priority was you, our membership. Today, our ADPH conference was over-subscribed for the first time, with a waiting list – that suggests to me a vibrant organisation, where people want to be a part of a body that learns, challenges and improves, together. I’m particularly thankful for the contributions that our members make through the Board, our strengthened Council and soon-to-be reinvigorated Policy Advisory Groups (PAGs); many have also been active through our peer mentoring, our immersive days (one on DsPH with expanded portfolios is coming up in March; do send ideas for further topics!) and the recent workshop for new DsPH – please join in and be part of our growth.  

I, with members of our brilliant ADPH team, have been visiting many of you across England – Cheshire and Merseyside, Yorkshire and the Humber, the east of England, the north east and the south east of England, and in Wales. I’ve enjoyed getting out to meet you and hear about your challenges and successes – you’re doing amazing work under increasingly difficult circumstances. What’s struck me is how committed you all are to improving the public’s health in our local places – but that we also have our heads raised to working to improve as a sector, respectively and collectively, in our regions and at a country level.  

I’m looking forward to connecting with those of you I haven’t yet met, when I complete this round of first visits early next year.   

I’ve also enjoyed hearing our members’ voices commenting on visions and plans and budget decisions, prevention, population health and public health interventions. For this contributes to what’s needed to deliver on my third and fourth priorities – promoting the unique leadership role of the DPH in local systems; and ensuring we continue to be a well-respected – and ‘edgy’ – voice for public health nationally.  

These priorities require a lot of relationship-building – with Public Health England and Public Health Wales, the LGA, ADASS, ADCS, the Faculty, Royal Society, and of course with the NHS. And the ADPH team and many of you, our members, have worked tirelessly to ensure that we get our voice into the many spaces and places shaping our context and our role as DsPH within this – from PHE’s and other agencies’ initiatives, to the NHS long term plan and the Secretary of State’s prevention vision, to the budget and forthcoming spending review. 

We need to – and are – raising our public voice and profile, developing our ‘edginess’ and trumpeting our successes – through tweeting and writing blogs and pieces for the LGC, HSJ, BMJ and elsewhere, and presenting our local work nationally, in the media, through social media, conferences or hosting visits. And we’ve also continued our presence in public hearings, parliamentary committees and other parliamentary bodies, and the many different summits and conferences.  

At November’s Health and Care Committee on the impact of the budget on health and care, the messages I gave were:  

  • Prevention – or health creation – needs investment in all the things that help make us happy, healthy and able to lead fulfilling lives – our childhoods, our friends and our play and learning, our houses and the places where we eat and live, and our occupation and income. Yet there has been a 40% cut to local government funding and a £700m cut to the Public Health Grant over the last 5 years (2014/15 – 2019/20)  
  • DsPH have been doing the best we can, and managed the cuts to the Grant through innovation and transformation of our teams and services (many provided by the NHS) and through a focus on integrating and strengthening local systems; but this is not sustainable   
  • We are local system leaders and ambitious for our population’s health, with proven positive impact – just think what more we could achieve if we were fully resourced. 

We need to continue to develop and strengthen our key messages and overarching narrative. We need you to help us do this with your examples of local successes – watch out for the requests for this, and please contribute yours.  

So, 200 days on: 

  • Priority 1: With Brexit on the horizon, there are many areas for concern in our society, and we need to keep calling these out and championing human rights and equity 
  • Priority 2: I’m loving the way we’re developing as a vibrant, member-led organisation 
  • Priority 3: We need to be much clearer on our impact and our successes 
  • Priority 4: As an organisation, we continue to be well-respected – but I definitely see our ‘edge’ developing. 

I look forward to working on these priorities over the next 200 days! 

by admin

Tackling alcohol, challenging the norm

September 28, 2018 in ADPH Updates, President's Blog, Publications by admin

I remember arriving in the UK as a Junior Doctor to work in the NHS in the mid-90s. The nurses were my new friends, and I used to join them at 9pm post shift for a crawl down the Derby Mile.

The bigger the group, the more the rounds to be gotten through before the 11pm closing hour bell rang. Then curry and Cobra at the end. Not something I had known before, but seemingly commonplace and well, normal.

I jumped into my new social scene with gusto, before long exceeding any recommended unit count, and rapidly putting on weight. A trip back home allowed for a welcome detox and sensible reflection and resolve.

Drinking too much. So easily done when it’s so normal.

The normalisation of harmful heavy drinking

Around that time, there seemed to be an explosion of new product development, new marketing approaches, new ‘normal’ ways of drinking – I remember the bursting onto the stage of alcopops, the surge of stag and hen dos, the creative, free-flowing Happy Hour promotions …

Licensed premises have exploded in numbers since 2005/6 – in my borough, there was a 41% increase. Schools and even hairdressers joined the corner stores and 24 hour pubs.

Since 1970 the amount of alcohol consumed per person has risen by 50% in the UK. Over that period alcohol has become relatively cheaper and more readily available. Alcohol is aggressively and expertly marketed and drinking has become a normal feature of everyday life.

Alcohol can play a positive social and economic role – and the large majority of people enjoy alcohol without harm. However, excessive alcohol use can have a harmful effect on individuals, their families and our community. The number of alcohol-related admissions to hospitals in England has risen yet again, with middle-aged drinkers most likely to be admitted, according to new Public Health England figures. We know we need to do something.

Navigating new approaches to population health

We know that public health issues such as these are too complex for a business as usual approach. We do need to challenge our own thinking and innovate – while developing, and keeping an eye on, the evidence of what works.

Partnering with Drinkaware could be just such a shift. However major changes in approach need careful consideration – a precautionary approach. The Alcohol Leadership Board should have been a place to talk this through with experienced and knowledgeable people.  The ADPH was therefore disappointed at PHE’s independent decision to collaborate with Drinkaware which has led us to a place where we, as a public health system in the broadest sense, have been, in effect, arguing publicly. And sadly, it is likely that this will lead to further confusion for the public around the actual messages about alcohol harm.

The key point is that alcohol is produced for profit. The more that is sold, the greater the profit. The industry spends billions creating new markets, promoting its product and lobbying for favourable business conditions. It spends some on corporate social responsibility (CSR).

A critical review in the latest (Sept) edition of WHO’s Public Health Panorama: Alcohol industry actions to reduce harmful drinking in Europe: public health or public relations? concluded that CSR activities conducted by the alcohol industry in the WHO European Region ‘are unlikely to contribute to WHO targets but may have a public-relations advantage for the alcohol industry’.

And we can all now quote the evidence review produced by PHE (2016) which demonstrated that education campaigns on their own, and particularly those with industry involvement, will not reduce alcohol harm.

These are some of the reasons why the public health community has a healthy scepticism of all things alcohol industry. As we noted in last week’s BriePH (the regular briefing for Directors of Public Health), ADPH has a clear Ethical Collaboration and Sponsorship Policy which sets out that the ADPH ‘will not work with, or accept donations from, organisations whose activities, policies, aims or objectives contradict or are inconsistent with its own’ – this includes partnerships with organisations involved in tobacco or alcohol manufacture. We regard Drinkaware as being too close to the alcohol industry. ADPH remains a member of the Alcohol Leadership Board. But we believe partnering with Drinkaware as they currently stand is unethical.

Missing the value DsPH can bring

I’m sure many of us can tell our own stories of how ‘normalised’ high risk drinking is in our communities and boroughs.

Directors of Public Health recognise that nationally developed social marketing campaigns such as the ‘One You’ have their part to play – and many have adapted these locally. Linking the One You brand with the Drinkaware campaign – without DsPH having any input – may adversely affect these local efforts. And declaring the campaign is ‘where the people are’ forgets that DsPH work closely with elected members and local residents. To some of us, it’s unhelpful and galling.

There is much work to do to reduce the harm. Minimum Unit Pricing, Health as a 5th Licensing Objective, adequate funding of treatment and recovery services and a levy on alcohol driven business to support the cost to councils and police of keeping safe and clean town centres are all part of that. The ADPH is committed to working with, challenging and supporting partners in the public health system – including PHE – to make sure we unite behind efforts known to have impact.