Statement of Principles – COVID-19: Contact Tracing

May 18, 2020 in ADPH Updates, Covid-19, Health Protection by Campbell Findlay

Introduction  

This paper sets out a ‘Statement of Principles’ which the Association of Directors of Public Health believes should underpin a coherent approach to contact tracing and how it links to the nationally led Test, Track and Trace programme.  

The ADPH supports the need to implement, at scale, a contact tracing programme. No single organisation or agency, whether national or local, can design and oversee this operation alone. The success of contact tracing will depend on a truly integrated approach between national and local government and a range of other partners across the UK.  

Directors of Public Health (DsPH) and local authorities are a key element of this. DsPH – and their teams – have extensive experience and knowledge of contact tracing, their local communities and the wider health and social care system. They have a critical contribution to ensuring contact tracing works on the ground.  

We will continue to work collaboratively; however, we have a duty to advocate strongly for elements we feel need to be in place to enable effective contact tracing.  

There is an urgent need to resolve how this programme, led nationally by the Department of Health and Social Care (DHSC), will translate and work at a local and regional level – including the role of local authorities, and DsPH specifically, and what resources, information and funding will be required to carry it out.  

Our principles  

To this end, we have identified some key principles to provide a framework for what an effective system should look like and support conversations the ADPH is having with partners and stakeholders.  

The Government needs to be serious about proper engagement with local authorities, recognising the contribution and wide-ranging roles and responsibilities of local authorities, and DsPH. To date, DsPH and local authorities have been disappointed at the limited extent the Government has involved local government in the development of all aspects of the Test, Track and Trace programme.  

  1. Whole systems approach – we must take a whole systems approach, with national and local partners working together to ensure the programme works effectively. No player has the resources, skills or expertise to make this happen on their own. 
  1. Subsidiarity – components of the system must be placed at the level that is best suited to the capabilities, skills and expertise of each agency and player. The role of regional and sub-regional structures in this must be carefully considered alongside local roles. 
  1. Localism – we need flexibility to determine the footprint for effective governance, whether that be: local authorities, Local Resilience Forums (LRFs), Integration Care Systems (ICSs), or other bodies. 
  1. Minimum viable products – we need to act swiftly and evolve interventions as we go with clarity on the roles for each part of the system and the outcomes required. 
  1. Avoid duplication – we must use and build on what is already happening – acknowledging that significant planning and preparations have taken place. 
  1. Integration – the pathways, systems and data sharing must be proactively integrated. There is currently limited connectivity between each of the components of the programme. 
  1. Responsiveness – greater responsiveness is needed to the differences and diversity in local communities, including issues around language, so that whatever is designed puts people at its heart.  
  1. Data sharing – proactive data sharing and flows for contact tracing, outbreak management and ongoing surveillance must be prioritised from the outset.  
  1. Capacity and resources – these must be provided across all levels to ensure the programme is run effectively and sustainably. We cannot presume this can be done with existing resources in view of the scale and complexity of what is needed. 
  1. Proper recognition of multiple local roles – there are multiple local roles that need to be recognised, these include: a) the role of the local authority, b) the role of the DPH within the local authority and c) the role of the DPH as a local system leader across the NHS, Local Authority and other partners. These must all be taken seriously. 
  1. Ownership – local outbreak plans need to be jointly owned under the leadership of the DPH, in line with government guidance on health protection and the role of the DPH. 

Our national asks  

The ADPH is committed to capturing and sharing what good looks like in terms of the role of the DPH and their team. 

In support of these principles, there are some key strategic considerations which should be recognised and addressed across the system. We will continue to advocate for the following at a national level. In doing so, our approach is to be as constructive as possible and as challenging, as necessary.  

  1. Multiple levels of geography – There are multiple levels that should be recognised and carefully considered, including: 
  • UK-wide and nations  
  • Local places  
  • PHE centres  
    • Sub-regional organisations e.g. LRF or ICS 

We must avoid the requirement to organise around multiple levels of geography.                                                 

  1. Co-design – the Government must act to ensure that partners are consulted on the whole programme. Not consulting ADPH and DsPH on all elements of the Test, Track and Trace programme has hampered progress to date. 
  1. Contextualise contact tracing – this is not being considered fully enough nationally. It is essential that the system is designed to reflect the diversity of our communities and the range of needs that exist, from language barriers to inequalities. 
  1. Both national and local – the contract tracing system will only work if the roles and responsibilities of partners at all levels are clear. The ADPH advocates for a ‘team of teams’ approach where every part of the system is supported and resourced to play to its strengths. 
  1. Establishing a reliable interface for data sharing between national and local agencies and clear, two-way communication on risks – Data sharing is needed across all parts of the Test, Track and Trace programme. 

This document was approved by the ADPH Council and first published on Monday 18th May 2020. It will be regularly updated.  

PDF version can be downloaded here

COVID-19 Prioritisation of Sexual & Reproductive Health Services

April 8, 2020 in ADPH Updates, Covid-19, Sexual and Reproductive Health by Lucy Sutton

In response to the COVID-19 public health emergency and its impact on maintaining ‘business as usual’ across health and social care; NHS England and Local Government were tasked with undertaking a rapid review of community health services with a view to detailing the elements of each that can be ‘stopped’, ‘partially stopped’, or should ‘continue’.

In relation to essential sexual & reproductive healthcare, the British Association for Sexual Health and HIV (BASHH); The Faculty of Sexual & Reproductive Healthcare (FSRH); and the British HIV Association (BHIVA) published a paper on 26 March 2020 titled Sexual Health, Reproductive Health and HIV Services: Emergency COVID-19 Contingency Plan Paper for Government.

It is the position of the ADPH that the recommendations, outlined in the documents below, summarise the urgent steps that must be taken to maintain, to our best ability under the unique circumstances, the wider public’s sexual & reproductive health. The protection of essential SRH services, and the changes in delivery necessary due to COVID-19, stand too as recommendations for essential provision aligned to Primary Care settings, both General Practice and Community Pharmacy.

FPH and ADPH Joint Statement on COVID-19

April 2, 2020 in ADPH Updates, Covid-19 by Campbell Findlay

The Faculty of Public Health (FPH) and the Association of Directors of Public Health (ADPH) are immensely proud of the role the UK public health workforce is playing in response to COVID-19. Day in and day out our members are working tirelessly to protect the public’s health in the most challenging of circumstances, and we thank our members for their energy, skill and expertise.

The public health workforce is at the forefront of efforts to tackle this global pandemic. Directors of Public Health and their teams are providing trusted leadership and advice to their local populations. For our part, as organisations, we are entirely focussed on enabling our members to carry out their responsibilities as effectively as possible and ensuring their voice is heard by national decision makers.

Collaboration is key in tackling the pandemic. We are working with our members to develop and maintain strong relationships between those working in public health on the frontline in local government and the NHS and numerous other settings, the Chief Medical Officers, the four public health agencies of the UK, and a range of professional bodies, providers and charities. 

The coming months will be enormously challenging for all of us in both our personal and professional lives and we urge kindness and respect for colleagues across the health and care sector, all of local government and civil society. We are now all working towards the same goal of saving lives and protecting the health of the public, and we will find strength in working as a unified system.

We will continue to support your vital work in whatever way we can, and once again thank you for your ceaseless commitment to the public’s health.

Toolkit for Implementing Quality in Public Health: A Shared Responsibility

March 25, 2020 in ADPH Updates, PH System, Sector Led Improvement by Teresa Grandi

Translating the principles from Quality in Public Health: A Shared Responsibility into practical programmes of quality improvement may not appear straightforward especially given the large number of quality improvement tools that are available within public health and the different settings where they could potentially be used.  Because of this the Quality in Public Health toolkit was developed to map individual quality improvement resources to the overall Quality in Public Health document and facilitate local use.  This work is part of overall service development and should be seen in the context of other work and resources such as Public Health England’s approaches for reducing health inequalities.

The Quality in Public Health toolkit is a spreadsheet designed for use principally by public health teams within local government in England as an aid to the implementation of Quality in Public Health: A Shared Responsibility and as a part of sector led improvement.  It can be used to help assurance processes and in conjunction with local quality systems as part of service development and delivery. The Quality in Public Health toolkit brings together and maps a range of individual quality improvement documents and tools, identifying appropriate settings for use and linking them to sections of the overall document.  This will help teams identify what tools they can potentially use in different circumstances for practical implementation of Quality in Public Health and how they can access them.

Click on the links below to download the toolkit, a short guide for its use and a document setting out how quality work fits together. For any queries please contact teresa.grandi@adph.org.uk.

Quality in Public Health – How it all fits together in Local Government

Toolkit

Toolkit Guide

by admin

A day in the life of…

March 23, 2020 in ADPH Updates, President's Blog by admin

Dr Jeanelle de Gruchy talks about her role as ADPH President during the response to COVID-19 and thanks Directors of Public Health for their energy, experience and calm leadership. 

This Thursday, I was due to go to South Africa for a holiday with my parents. From looking forward to family fun, I’m now worrying about their health and trying to advise from afar on how they can shield themselves while maintaining their physical fitness, social interaction and sense of purpose. My partner is worried about her daughter Beth, a junior doctor on an infectious diseases ward in Glasgow’s main hospital – and we can’t even redirect our holiday plans to go to visit her.

The fact is that all of us have our own particular circumstances and worries to deal with in this universal crisis. COVID-19 is demonstrating how interconnected we’ve become in our global and yet increasingly unequal world. 

For many of us too, the COVID-19 pandemic is also blurring our personal and professional lives in a major way. Every day I am struck by the energy, experience and – perhaps above all – calm leadership being provided by public health professionals in the UK. Directors of Public Health have been in the thick of leading the local response to the virus from the very start. In the early containment phase, our already strong relationships with PHE and other partners were critical in enabling us to perform a key local system leadership role and ensure joined-up action.

As a membership organisation, the ADPH is always focussed on facilitating connections and providing support. DsPH have been able to connect quickly – formally and informally – sharing intelligence, resources and encouragement. From local system leadership to the shaping of national guidance (or just getting on and producing critical materials ourselves) we’ve been committed, measured, agile and decisive in getting stuck in to do what needs doing.

We – the ADPH team, Jim McManus our Vice-President and myself, our Board and many of our DPH members – have ensured that intelligence has flowed between national and local; through regular telecons between members and the Chief Medical Officer, a host of interactions with officials and advisors at DHSC, NHSE, MHCLG and others, and Jim and myself attending a roundtable chaired by the Prime Minister where we discussed the local government response.

We’ve had a clear national and local public leadership presence too. Twitter has been electric with our advice, commentary and innovative approaches to getting across key messages. Many DsPH have made assured and reassuring media appearances across the country; we’ve shone a spotlight on the DPH role on the ground, through a comment piece in the Municipal Journal, coverage in The Times and appearances on BBC Radio 4’s the World at One and PM programmes. For Radio 4, I had 3 hours on a Saturday afternoon from contact to interview and I, in that short space of time, had productive interactions with the Chief Medical Officer, Chief Executive of PHE, LGA Senior Adviser for Public Health, and our ADPH Chief Executive, Vice-President and Head of Policy. This epitomised for me the strength of our public health leadership where we bring our unique viewpoints, understand the positions of others, and combine them to provide much needed system strength for the immense task we face.

People everywhere have questions about different aspects of the situation; some are expressing what they strongly feel are the answers. This is a rapidly evolving situation – and managing the communications across so many parts of our society has clearly been difficult. But we know that people look for credibility, reliable advice and leadership. We have confidence in the considerable scientific public health endeavour that is supporting national decision-making. A bad course of action is for us to challenge, undermine or generate uncertainty around the approach for the sake of it. That will further increase confusion and anxiety. Our view is that where people with legitimate expertise consider that there are areas of concern, they have a responsibility to make these known through constructive professional communication, rather than via mass media. Consistent messaging and credible leadership remain core elements of an effective public health emergency response.

I pay tribute to the dedication of Directors of Public Health and our amazing teams – many senior public sector leaders recognise the incredible, expert, hard work being done by our members, and know that we’re a key ‘go to’ local expert and leader.

Unfortunately, this hasn’t always been the case. What has upset some of our members the most, despite leading so much of this work, is being left time and time again off key communications or guidance development by NHS England and some government departments. It’s not good enough – and it slows down our response at a time when we can least afford it.

While the focus on the NHS is understandable, the critical role of local government – and other sectors (such as schools and the voluntary and community sectors) – in all they have to step up to do for our communities during this crisis, is seldom mentioned. Collaboration is our greatest asset. We need to boost the morale of all key workers, and we should be doing more to recognise them.

The next few months will be uniquely challenging – from the immediate saving of lives to managing and mitigating the fall out on our residents’ mental health, debt, relationships, loss and loneliness, exhaustion, inequalities. This is a marathon, not a sprint and we’ll need to ensure that we – and those we work with – are able to pace ourselves. I am confident that we, as DsPH collectively, will do everything we can to support each other with our mental and physical wellbeing. I’ve been totally bowled over by how DsPH across the UK are spending time sharing, guiding, mentoring, providing mutual aid, and allowing each other to simply ‘wobble’ in safe spaces. 

One thing that some DsPH have shared on Twitter is what a day in their life is currently like – cathartic, entertaining, illuminating… I’d like more of you to share your highs and lows by using the hashtag #adayinthelifeofaDPH and including @adphuk

I’m immensely proud of all that DsPH, their teams and all those we work with have done so far, and wish you all strength and support to continue to meet the challenge as best as we possibly can.   

by admin

COVID-19: The ADPH Approach

March 20, 2020 in ADPH Updates by admin

Like every organisation, the Association of Directors of Public Health is adapting what we do and the way we do it in response to COVID-19, based on the latest national advice and information.

We wanted to explain our approach.

For the foreseeable future, our staff are working remotely and flexibly. The top priority of our members – Directors of Public Health and their teams – is playing their part in national and local efforts to minimise the impact of COVID-19 on the health and wellbeing of the UK.

Our top priority is supporting them.

We will continue to do so by facilitating the link between Directors of Public Health, the Government, the CMOs, PHE and other system partners; ensuring their voices and experiences are heard by decision-makers; providing advice and disseminating resources; promoting national advice and guidance in the media; being an engaged and collaborative partner and facilitating peer-to-peer support and mentoring.

With respect to our projects and programmes, we are actively reviewing our plans. Changes will include postponing events, or delivering them differently, and de-prioritising our involvement in some policy issues. We will however continue with as much of our work as practically possible. These actions will help ensure our members are able to focus on their responsibilities in relation to COVID-19.

To get in touch with ADPH staff, please follow this link.

ADPH responds to announcement of Public Health Grant allocation 2020-21

March 17, 2020 in ADPH Updates, PH Funding, Uncategorized by Campbell Findlay

Dr Jeanelle de Gruchy, President, Association of Directors of Public Health, said:

“It is welcome that the Government has taken a positive step forward after year upon year of deep cuts to local public health. We now have the certainty the ADPH has been calling for since December and Directors of Public Health can focus on the nation’s number one priority: ensuring the best possible response to coronavirus.

“The reality on the ground is that these allocations will not reverse the staff and services lost overnight, whether that be in relation to early years interventions, sexual health services, drug and alcohol treatment or capacity to prepare for outbreaks like coronavirus. Directors of Public Health will continue to face tough decisions. What is needed, through the upcoming Spending Review, is a significant, multi-year settlement for public health – just like the NHS. 

“There is a growing consensus from commissioners, providers, charities and professional bodies that long-term investment in local public health is essential to reduce pressure on the NHS, narrow inequalities, improve wellbeing, drive productivity and maintain a resilient health protection system.”

ADPH responds to Budget 2020

March 12, 2020 in ADPH Updates, PH Funding, PH System by Lucy Sutton

Responding to the budget announcement on 11th March 2020, Dr Jeanelle de Gruchy, President, Association of Directors of Public Health, said:

“Given the scale of the challenge in relation to coronavirus, we welcome the Government’s announcement of a significant funding package to support public services, businesses and individuals. Every part of our public services called on to respond to this emergency requires additional funding, including local council public health with its statutory responsibility for local health protection. 

“Improving the health and wellbeing of our communities – and narrowing the health inequalities between them – needs investment in both the infrastructure of our places as well as services to support people to thrive in them. Extra investment in drug treatment for people experiencing rough sleeping, for example, is important but this must be seen in the context of £850m of cuts to the public health grant since 2015/16 which includes these services. The Budget offered mixed messages on public health. We are pleased to see the tax escalator on cigarettes will continue at 2% above inflation, although continuing to freeze both alcohol duty and fuel duty sends the wrong signal about the way the tax system can, and should, be used to promote the kind of behaviour change needed from businesses and individuals to create a healthier society. 

“Yesterday the Secretary of State for Health and Social Care promised a real-terms increase in public health budgets for every local authority which would be a positive step forward. With less than 3 weeks until the new financial year this announcement, with the full details, is beyond urgent. Ahead of the upcoming Spending Review, we are calling on the Government to move on from years of cuts and uncertainty with a long-term settlement for public health.”

ADPH Budget Submission, Spring Budget 2020

March 11, 2020 in ADPH Updates, PH Funding, PH System, Policy Statements by Lucy Sutton

This statement sets out our key priorities in advance of the Budget 2020. The full statement can also be downloaded here.

Summary of key recommendations

  • Investment in public health must be increased. The Spending Review must deliver a sustainable package for public health in local government. The Public Health Grant needs at least £1bn more a year to reverse years of cuts to public health funding.
  • The Government should adopt a ‘health in all policies’ approach to decision-making and policy development, assessing the long-term health impact for all policies.
  • The Government should make tackling the social determinants of health and building wellbeing into policy decision making and funding allocation a cross-government priority, supported by a new ‘health index’ and better utilisation of existing ONS wellbeing statistics.
  • The Government should implement a minimum price of 50p per unit of alcohol.
  • The Government should reintroduce the tax escalator on alcohol at 2% per annum ahead of inflation.
  • The Government should implement a tax or levy on tobacco manufacturers to help cover the cost of smoking to the NHS and wider society.
  • The Government should increase the tobacco tax escalator from 2.5% to 5% above inflation.
  • The Government should reintroduce binding national targets to reduce child poverty.
  • The Government should incentivise the use of low-emission vehicles and Vehicle Excise Duty should be adjusted to reflect the impact of diesel vehicles on levels of nitrogen dioxide in the atmosphere.
  • The Government should commit to a cost-benefit analysis of a national diesel scrappage scheme in England. 
  • The Government should prioritise active travel in transport policy and continue to invest in infrastructure for active travel.

Investment in public health must be increased 

The public health grant has been cut by £850 million since 2014/15 and between 2010 and 2020, councils will have lost almost 60p out of every £1 the Government had provided for services. At the same time additional demands continue to be created. For example, in 2018 there were 3,561,548 new attendances at sexual health clinics in England compared with 2,940,779 in 2013, an increase of 21%.[i] With population growth factored in, £1bn a year will be needed to restore funding to 2015/16 levels, according to the King’s Fund and the Health Foundation.[ii]

Reductions to funding for public health represents a short-term approach and ignores the much larger long-term costs associated with not investing in public health. Inversely, there are great dividends to be paid, both to the economy and society, through investing in public health initiatives. A systematic review identified the median return on investment for local public health interventions as 4:1.[iii] Further analysis of the public health grant demonstrates that prevention is indeed cheaper than cure and that cuts to public health grant funded services directly impact on downstream NHS demand.[iv]

Directors of Public Health have been acting to manage the cuts and the increasing demand and at the same time modernise services. Since taking over responsibility for public health in 2013, councils have maintained or improved 80 per cent of the public health outcomes of the nation. However, this cannot last. Further reductions in public health services – including sexual health, smoking cessation, substance misuse and health visiting services – are now inevitable if the Spending Review does not deliver significant and sustainable investment in public health. Reductions in overall local authority budgets are also adversely impacting on health and wellbeing locally.

In addition to impacting the ability of local authorities to deliver vital public health programmes, cuts to the public health budget risk undermining the role Directors of Public Health play in addressing the social determinants of health and delivering a place-based population health approach. The experience and skills of Directors of Public Health are essential in contributing to emerging policy challenges, such as serious violence and air quality, and system reforms, such as ICSs. However, this role cannot be adequately performed without enough resources and staffing capacity in public health teams. 

Recommendation: Investment in public health must be increased. The Spending Review must deliver a sustainable package for public health in local government. The Public Health Grant needs at least £1bn more a year to reverse years of cuts to public health funding.

Health in all policies

In 21st century Britain, life expectancy is stalling, and health inequalities are rising; with the gap in life expectancy between the richest and poorest areas of England and Wales widening over the past decade. Whilst health services, delivered by the NHS and public health teams in local government, play an important role in keeping us healthy, it is the economic, social and environmental conditions we live in – what are often referred to as the social determinants of health such as poverty, education, housing and more broadly the kind of ‘places’ we call home – that truly define our health and wellbeing.

It is apparent from the Marmot Review: 10 Years on report that we must see vastly more action in the next 10 years than we have seen done in the previous 10 years. It is clear that progress is only possible when we address the causes – not just the symptoms – of ill health.

We would urge the government to adopt a health in all policies approach to policy making including Budget decisions and to consider the impact of any tax or benefit changes on health and health inequality. We need to see a shift in focus across government to prevention and early intervention. This is not only because of the expense and distress caused by preventable disease but also because of the importance to individual lives, communities, the economy and the sustainability of the health and care system. We must invest in enabling people and communities to prioritise their long-term health and wellbeing.

Wellbeing should be built into the fabric of Government decision-making when it comes to both policy-making and funding allocation. Wales has already made a vital step towards realising this ambition, through the introduction of the Future Generations Wellbeing Act . Similarly, in Scotland, there is now a vision for national wellbeing in the form of the National Performance Framework . These efforts must be matched in England – the proposal to create a ‘health index’, alongside existing wellbeing data collected by the Office for National Statistics, could provide a framework to drive change and embed accountability across Whitehall.

Recommendation: The Government should adopt a ‘health in all policies’ approach to decision-making and policy development, assessing the long-term health impact for all policies.

The Government should make tackling the social determinants of health and building wellbeing into policy decision making and funding allocation a cross-government priority, supported by a new ‘health index’ and better utilisation of existing ONS wellbeing statistics.

Supporting the implementation of the NHS Long Term Plan

Directors of Public Health strongly support the plan’s renewed focus on prevention, health inequalities and a population health approach. However in order to implement the long term plan and deliver real benefits to patients, the investment in NHS England over the next 5 years needs to be matched with funding to ensure that social care and public health are able to play their part in supporting people to live healthy, high quality lives.

The NHS’s priorities on prevention – which includes action on smoking, obesity and type 2 diabetes, alcohol and air pollution – are complementary to local government responsibilities for funding and commissioning public health. The delivery of the NHS long plan will therefore depend largely on the local implementation of the national objectives and support for public health teams to deliver vital services – including weight management services, drug and alcohol misuse services, sexual health services and early years services.

Local partnerships are essential to deliver sustainable changes. The delivery of the NHS Long Term plan and proposals in the green paper ‘Advancing our health: prevention in the 2020’ depend on collaboration between the NHS, local government and the Voluntary and Community Sector.Local authorities have a clear and distinct role in improving the health of their population and in convening the local system to work together through Health and Wellbeing Boards. Local accountability matters and actions which have the support of communities and which are actively promoted by councils have the greatest chance of being sustained. New structures and arrangements through Integrated Care Systems, provide a valuable opportunity to work pragmatically across organisational boundaries, to join up local systems and boost efforts to improve our populations’ health and wellbeing. The Director of Public Health provides a key link between the NHS and local authority.

Action needed on alcohol pricing 

Alcohol is the leading risk factor for ill-health, early mortality and disability among men and women aged 15-49 years in the UK and the harm from alcohol affects a range of other public health outcomes.[v] Estimates show that the social and economic costs of alcohol-related harm amount to £21.5bn – this includes the costs associated with deaths, the NHS, crime and lost productivity.[vi]

As local commissioners of drug and alcohol treatment services, Directors of Public Health are only too aware of the devastating impacts that alcoholism can have on individuals and families. Tackling harms associated with the consumption of cheap alcohol is a tangible way in which the government can improve the health of many people, especially the most vulnerable.  

Minimum Unit Pricing (MUP) is a proven policy mechanism to do this and is the number one policy priority for Directors of Public Health.[vii][viii] MUP is highly targeted to have the greatest impact on drinkers who consume alcohol at a harmful level. However, it would have an imperceptible impact on the cost of alcohol consumption for lower risk drinkers and would not lead to changes in pub prices. Recent modelling work by Sheffield University and Cancer Research UK found that over a 20 year period, a 50p minimum price per unit of alcohol in England could reduce deaths linked to alcohol by around 7,200, and further reduce healthcare costs by £1.3 billion. [ix]

MUP was implemented in Scotland in May 2018, and will be introduced in Wales in early 2020. The initial figures from the official Scottish evaluation on the quantity of alcohol sold per adult is encouraging. In the first year the 50p minimum price was implemented, average consumption of alcohol fell by 3% to the lowest level since records began in 1994. At the same time, consumption increased by 1.5% in England and Wales, where MUP is not in place.[x]

Furthermore, the government should reintroduce the tax escalator on alcohol at 2% per annum ahead of inflation. Research by the University of Sheffield found that cuts in alcohol duty since 2012 have led to 2,223 additional deaths and almost 66,000 additional hospital admissions in England and Scotland between 2012 and 2019. This has resulted in £341 million additional costs to the NHS. The same report also shows that above inflation increases in alcohol duty, starting from the forthcoming Budget could have dramatic benefits: Increasing alcohol duty by 2% above inflation every year between 2020 and 2032 would result in 5,120 fewer alcohol-attributable deaths in England and Scotland.[xi] It would further reduce alcohol-related criminal offences by 263,084 in England and 31,992 in Scotland over the period to 2032, reducing the cost to society by £901m and £279m respectively.[xii]

Recommendation: The Government should implement a minimum price of 50p per unit of alcohol.

The Government should reintroduce the tax escalator on alcohol at 2% per annum ahead of inflation.

The tobacco industry should contribute to the cost of smoking 

Smoking is the single largest cause of preventable death and one of the largest causes of health inequalities in England, causing about 79,000 preventable deaths a year. The total cost of tobacco to society (in England) is approximately £12.9 billion per year, and is spread across the NHS, social care, employers and wider society. Revenue from tobacco taxation does not cover this cost. Total tobacco revenue is currently around £12.3 billion annually.[xiii]

The ambition of delivering a Smokefree generation by 2030 will not be met unless the Government is able to find a sustainable source of funding needed to deliver a comprehensive tobacco control programme. As outlined in the Prevention Green Paper, the Government is exploring options for raising funds from the tobacco industry via a ‘polluter pays’ principle. This proposal is strongly supported by Fresh and over 120 other health-related organisations, including ADPH.[xiv] It is also supported by members of the public.[xv]

The levy should be structured as a charge on each tobacco manufacturer, designed to deliver a fixed sum annually to the DHSC (using the Health Act 2006) to be used to fund high impact, evidence-based measures to encourage smokers to quit, and discourage youth uptake. The funds should not exclusively be put towards stop smoking services but more broadly for measures which will reduce prevalence including delivery of national and regional public education campaigns and work at regional level including on illicit tobacco.

Raising tobacco taxes is also one of the most effective mechanisms for reducing tobacco consumption.[xvi] Modelling by Cancer Research UK and the UK Health Forum in 2015 showed that, based on the population data available at the time, increasing the tobacco tax escalator to 5% above inflation would accelerate the decline in smoking prevalence among both men and women. Adult smoking prevalence would decline to 6% in men and 6.5% in women by 2035, compared to smoking prevalence estimates being 10% for both men and women if the tobacco tax escalator remained at 2.5%.[xvii]

Recommendation: The Government should implement a tax or levy on tobacco manufacturers to help cover the cost of smoking to the NHS and wider society.

The Government should increase the tobacco tax escalator from 2.5% to 5% above inflation.

Action is needed to reduce child poverty

Child poverty in the UK is rising. In 2017/8 there were 4.1 million children living in poverty in the UK. This is predicted to rise to 5.2 million by 2022.[xviii] Child poverty is associated with poorer health, social, psychological and educational outcomes.[xix] The government should restore national binding targets to reduce child poverty and introduce a dedicated national child poverty strategy. 

Recommendation: The Government should reintroduce binding national targets to reduce child poverty.

Improving air quality should be a budget priority

Outdoor air pollution costs the UK economy £20 billion per year and has an effect equivalent to 40,000 deaths a year in the UK by increasing risk of diseases such as heart disease, stroke, respiratory diseases and cancer.[xx] [xxi] A recent WHO report attributed a mortality rate of 25.7 per 100,000 to outdoor and indoor air pollution in the UK. This is higher than mortality rates in Spain, Portugal, and France.[xxii]

The proposals outlined in the Clean Air Strategy need to be implemented, with further action required to address the complex environmental and social factors contributing to poor air quality. The government should incentivise the use of low-emission vehicles and use fiscal levers to increase the use of less polluting vehicles, as well as require housing developments to install infrastructure fit for future new technological vehicles, making that switch easier for the population. The government should lead the way by switching to lower polluting vehicles for the NHS and other government fleet vehicles.

At the same time, the government should prioritise active travel in transport policy and invest in infrastructure for active travel. Prioritising initiatives that maximise the benefits to both health and the environment represents best value for money as well as having a greater positive impact overall. 

Recommendation: The Government should incentivise the use of low-emission vehicles and Vehicle Excise Duty should be adjusted to reflect the impact of diesel vehicles on levels of nitrogen dioxide in the atmosphere.

The Government should commit to a cost-benefit analysis of a national diesel scrappage scheme in England. 

The Government should prioritise active travel in transport policy and continue to invest in infrastructure for active travel.

Association of Directors of Public Health

February 2020


[i] Public Health England, Sexually transmitted infections and screening for chlamydia in England (2018) (2019)

[ii] The King’s Fund, Public health: our position [https://www.kingsfund.org.uk/projects/positions/public-health] accessed 13 February 2020

[iii] Masters R, Anwar E, Collins B, et al (2017). Return on investment of public health interventions: a systematic review Journal of Epidemiology Community Health, 71, 827-834.

[iv] Stephen, M, Lomas J & Claxton K (2019) Is an ounce of prevention worth a pound of cure? Estimates of the impact of English public health grant on mortality and morbidity. CHE Research Paper. Centre for Health Economics, University of York, UK.

[v] Public Health England, Alcohol commissioning support: principles and indicators: Guidance (2018)

[vi] Public Health England, Alcohol commissioning support: principles and indicators: Guidance (2018)

[vii] Public Health England, The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Polices: An evidence review (2016)

[viii] Association of Directors of Public Health, ADPH English System Survey 2019 – summary report (2019)

[ix] Angus, C., Holmes, J., Pryce, R., Meier, P., & Brennan, A. (2016). Alcohol and cancer trends: Intervention Studies University of Sheffield and Cancer Research UK. Available at: http://www.cancerresearchuk.org/sites/default/files/alcohol_and_cancer_trends_report_cruk.pdf

[x] NHS Health Scotland (2019) MESAS Monitoring Report 2019

[xi] Angus, C & Henney, M (2019), Modelling the impact of alcohol duty policies since 2012 in England & Scotland. Available at: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp38102019.pdf

[xii] Angus, C & Henney, M (2019), Modelling the impact of alcohol duty policies since 2012 in England & Scotland. Available at: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp38102019.pdf

[xiii] Action on Smoking and Health, The Economics of Tobacco (2017)

[xiv] Annual online survey by YouGov for ASH. Total sample size in 2019 for England was 10338 adults (and 12393 for GB). Fieldwork was undertaken between 12th February 2019 and 10th March 2019. The surveys are carried out online and the figures have been weighted and are representative of all English adults (aged 18+).

[xv] Opinion research by YouGov for ASH. Total sample size was 12696 adults. Fieldwork was undertaken between 16th February 2017 and 19th March 2017 https://ash.org.uk/media-and-news/press-releases-media-and-news/12-years-on-from-england-going-smokefreesupport-for-the-government-to-do-more-to-tackle-smoking-is-continuing-to-grow/   

[xvi] WHO. Article 5.3 of the WHO Framework Convention on Tobacco Control

[xvii]  Knuchel-Takano, A., Hunt, D., Jaccard, A., Bhimjiyani, A., Brown, M., Retat, L., Brown, K., Hinde, S., Selvarajah, C., Bauld, L. and Webber, L. (2017). Modelling the implications of reducing smoking prevalence: the benefits of increasing the UK tobacco duty escalator to public health and economic outcomes. Tobacco Control, 27(e2), pp.e124-e129.

[xviii] The Institute for Fiscal Studies, Living standards, poverty and inequality in the UK: 2017–18 to 2021–22 (2017)

[xix] Wickham S, Anwar E, Barr B, et al (2016). ‘Poverty and child health in the UK: using evidence for action’, Archives of Disease in Childhood, 101(8), 759-766.

[xx] Royal College of Physicians, Every Breath We Take: The Lifelong Impact of Air Pollution (2016)  

[xxi] Public Health England, Clean Air Day – taking steps to reduce air pollution [https://publichealthmatters.blog.gov.uk/2017/06/15/clean-air-daytaking-steps-to-reduce-air-pollution/]

[xxii] World Health Organisation, World health statistics 2018: monitoring health for the SDGs (2018)

New research shows alcohol minimum unit price could save almost 8,000 lives in north of England

February 28, 2020 in ADPH Updates, Alcohol and Drugs by Campbell Findlay

High risk drinkers would cut their consumption by the equivalent of 14 bottles of vodka a year

Civic leaders are calling for the urgent introduction of a minimum unit price (MUP) for alcohol in England after new evidence revealed that it could save almost 8,000 lives across the North over the next 20 years.

The call comes just days before MUP is introduced in Wales; almost two years since its arrival in Scotland; and weeks after England saw hospital admissions caused by alcohol reach record levels.

The research from the University of Sheffield reveals that a 50p MUP in England would see alcohol consumption in some areas in the North falling by almost twice the national average, leading to greater reductions in alcohol attributable deaths, hospital admissions and crimes.

Almost half of the deaths and hospital admissions prevented and 39 per cent of the crimes avoided would come from the three Northern regions – the North West, North East and Yorkshire and the Humber.

The Association of Directors of Public Health (ADPH) has welcomed the research, with Alice Wiseman, Director of Public Health for Gateshead and ADPH Alcohol Policy Lead, commenting:

“This research provides the most detailed picture yet of the effect of MUP in parts of England. Risky drinkers in England consume more than two-thirds of all the alcohol sold and evidence shows a strong link between consumption and affordability. A measure like MUP will have the biggest impact on the heaviest at-risk drinkers, while leaving the average moderate drinker virtually untouched. 

“It would also have a huge impact in the North, which has some of the highest levels of alcohol harm in the country, with rates of alcohol attributable hospital admissions being higher in many places than those found in Wales, where MUP is scheduled to be introduced next week.

“It would play an important role in reducing health inequalities, including by closing the health gap between North and South. This is a measure whose time has come and it should be introduced in England without delay.”

Key findings from the research indicate that in the North:

  • An estimated 7,816 deaths attributable to alcohol would be prevented over the next 20 years, 48 per cent of the total for England
  • Alcohol consumption would fall by 6 per cent in the North of England, with by far the biggest reductions coming amongst the heaviest drinkers. High risk drinkers would cut their consumption by the equivalent of around 14 bottles of vodka a year, while the average moderate drinker would reduce their drinking by less than half a bottle of vodka a year
  • Alcohol attributable hospital admissions would reduce by an estimated 13,820, reducing pressure on the NHS, with people from the poorest communities seeing the biggest falls
  • The criminal justice system would also benefit, with crimes falling by 21,128 a year.
  • Researchers estimate that cost savings to the NHS in the North alone would amount to £37m a year

Professor Alan Brennan from the University of Sheffield’s School of Health and Related Research who led the research team said:

“This research is built on a wealth of evidence which shows that the amount we consume is closely linked to the affordability of alcohol. MUP is linked to the strength of the product and works by setting a floor price below which a product cannot be sold. In that way, it increases the price of the cheapest drinks which are most typically consumed by increasing and higher risk drinkers.

“The North of England has some of the highest levels of alcohol harm in the country and, as we discovered, some of the cheapest prices, so it was no surprise that it would be particularly effective in those areas.”

Alcohol harm is particularly acute in areas of deprivation even if consumption is no higher – something known as the alcohol harm paradox. The research indicates that the benefits of MUP would be particularly felt in these areas and so would help reduce health inequalities.

David Parr, the Chief Executive of Halton Borough Council, which has been calling for MUP, said:

“It is clear from Sheffield University’s work that the North of England has much to gain from the introduction of MUP in England. It would save lives, cut crime and reduce the pressure on overstretched public services. Critically, it would improve the health in our most vulnerable communities at a time when they are struggling. If this measure is good enough for our neighbours in Scotland and Wales, it is good enough for the North of England. Further delay simply puts more lives at risk and we urge the Government to introduce it without delay.”

Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, said:

“As a liver physician based in Liverpool I have seen the increasing harm caused in northern England by the widespread availability of cheap alcohol. MUP targets those products typically bought by those people who end up in our hospital wards. 

“This research provides yet more evidence that MUP is an effective and targeted measure which will reduce harm and reduce the pressure on the NHS. Its introduction would undoubtedly be good news for the North, but it would also save lives in communities across England and I urge the Government to introduce it as soon as possible.”

ENDS

 Notes to editors

  • Introduced in Scotland in May 2018, Minimum Unit Price (MUP) is a measure that targets the cheapest, strongest alcohol typically consumed by heavy drinkers. It does that by setting a threshold price below which alcohol cannot be sold.
  • Risky drinking is defined as those people above the low risk guideline level of 14 units of alcohol a week for men and women

The Association of Directors of Public Health

The Association of Directors of Public Health (ADPH) is the representative body for Directors of Public Health (DsPH) in the UK. It seeks to improve and protect the health of the population through collating and presenting the views of DsPH; advising on public health policy and legislation at a local, regional, national and international level; facilitating a support network for DsPH; and providing opportunities for DsPH to develop professional practice.

The Association has a rich heritage, its origins dating back 160 years. It is a collaborative organisation working in partnership with others to maximise the voice for public health.

The University of Sheffield

With almost 29,000 of the brightest students from over 140 countries, learning alongside over 1,200 of the best academics from across the globe, the University of Sheffield is one of the world’s leading universities.

A member of the UK’s prestigious Russell Group of leading research-led institutions, Sheffield offers world-class teaching and research excellence across a wide range of disciplines.

Unified by the power of discovery and understanding, staff and students at the university are committed to finding new ways to transform the world we live in.

Sheffield is the only university to feature in The Sunday Times 100 Best Not-For-Profit Organisations to Work For 2018 and for the last eight years has been ranked in the top five UK universities for Student Satisfaction by Times Higher Education.

Sheffield has six Nobel Prize winners among former staff and students and its alumni go on to hold positions of great responsibility and influence all over the world, making significant contributions in their chosen fields.

Global research partners and clients include Boeing, Rolls-Royce, Unilever, AstraZeneca, Glaxo SmithKline, Siemens and Airbus, as well as many UK and overseas government agencies and charitable foundations.

National Institute for Health Research

The National Institute for Health Research (NIHR) is the nation’s largest funder of health and care research. The NIHR:

  • Funds, supports and delivers high quality research that benefits the NHS, public health and social care
  • Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
  • Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
  • Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
  • Partners with other public funders, charities and industry to maximise the value of research to patients and the economy

The NIHR was established in 2006 to improve the health and wealth of the nation through research and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR commissions applied health research to benefit the poorest people in low- and middle-income countries, using Official Development Assistance funding.

This work uses data provided by patients and collected by the NHS as part of their care and support and would not have been possible without access to this data. The NIHR recognises and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care. www.nihr.ac.uk/patientdata

Contact information

Email: annah@gardiner-richardson.com

            sarahj@gardiner-richardson.com

Telephone: 0191 2614250

Association of Directors of Public Health

February 2020