North West Registrars June 2015
Welcome & Introduction Advocacy is included in the Faculty of Public Health mission statement, but how many of us in public health truly feel we know what it means to be an advocate or how to go about it? This topic has created much debate amongst registrars in the North West and led to A Passion for Public Health: Advocacy in Action becoming the theme for our 2015 Annual Event and this PH1 edition.
advocacy is and how it can be used to improve health and wellbeing. The two key-note speakers from our annual event set out two very different approaches to public health advocacy: their challenging and thoughtprovoking talks are reproduced here. The interview with local North West public health advocate Andrea Crossfield, CEO of Tobacco Free Futures, highlights how a passion for a particular public health issue can lead to change and help people to improve their health and wellbeing.
Our Annual Event challenged us to talk on our public health passions for soapbox presentations. Our passions in the North West range from toilets to twins, domestic violence to sleep to name but a few. We hope you enjoy finding out more about the wide and varied public health passions in the North West. Advocacy continues to be a theme that we as North West registrars are developing and we hope this edition of PH1 will encourage you to advocate for your public health passion too.
This edition explores what “Our overarching mission is to promote and protect the health and wellbeing of everyone in
society by playing a leading role in assuring an effective public health workforce, promoting public health knowledge and advocating for the very best conditions for good health.” Faculty of Public Health
Silver Jubilee Bridge, Runcorn
© Halton Borough Council
PH1: Advocacy in Action
Welcome to the June 2015 edition of PH1. This edition focuses on public health advocacy.
Inside this issue:
My Journey to Public Health Advocacy
Page 2
North West School of Public Health Annual Event 2015
Page 2
A Passion for Public Health: Advocacy in Action—Keynote Speakers
Page 3
Taking Action - North West Public Health Registrar’s Group
Page 5
Soapbox Summaries
Page 6
Advocacy in Action - Interview with Andrea Crossfield, CEO of Tobacco Free Futures
Page 16
My Journey to Public Health Advocacy In Spring 2014, as I was preparing for my Part A exam resit I was suddenly filled with doubt and disillusion - ‘What was I doing and why was I putting myself and young family through this?’I could very easily have been happy and content working as a Physiotherapist in a Teaching Hospital. I tried to remember the drivers that lead me to this pathway of Public Health Training. I had been inspired by the first pioneers in public health, seeking solutions to cholera, smallpox, tuberculosis and working among the most deprived populations. Tackling disease through education, housing, sanitation, environmental health and vaccination had proven to be highly effective in improving public health. Yet, I had witnessed health and social inequalities in the UK and overseas. I have seen the impact of poor health, poor housing and poor sanitation. I am passionate about toilets, gender-based violence, migrant health, disability, HIV
and TB. I believe public health in the world has a high mountain to climb and I want to be a part of this challenge.
Also, what did advocacy mean within the changing landscape of public health?
I recalled during my Masters in Public Health a Professor asking “Who wants to change the world?”. Yes, I did want to change the world. The professor remarked “I used to believe that I could change the world, but now I’m just happy to exist”.
Was I even allowed to speak out when employed by the NHS, based in a local authority?
At that moment I realised that I did not want to be a Speciality Registrar in Public Health ‘just happy to exist’. I did not believe that Chadwick, Duncan, Snow, Fry and Jenner were ‘just happy to exist’. I wanted to be able to make a difference and improve the health of individuals, the most vulnerable, those without a voice.
I posed these questions to colleagues and realised that the same deliberations were occurring across the region. The theme for the 2015 Annual Event ‘A Passion for Public Health: Advocacy in Action’ was born. Hayley Teshome Tesfaye Public Health Registrar
“A small group of thoughtful, committed citizens can change the world; indeed,
So, yes on reflection the agony of Part A was worth it!
it’s the only thing that ever has”
However, how could I make my voice heard and advocate on the issues which drive me?
Margaret Mead, Anthropologist
North West School of Public Health Annual Event 2015 For the last 3 years, the North West Registrar’s Network has organised the highly successful School of Public Health Annual Event. In 2015 the event A Passion for Public Health: Advocacy in Action was held on 31 March at the University of Central
Lancashire, Preston. The event attracted 85 delegates from diverse public health fields across the North West including academia, local authorities, NHS England, PHE, School of Public Health Board members and third sector organisations.
All delegates were invited to speak out on their public health passions in Soapbox Sessions; three minute informal verbal presentations followed by discussion with small groups of colleagues in break out rooms. Soapbox sessions were extremely well received by delegates and highly evaluated.
Graffiti Wall
North West School of Public Health Annual Event 2015
Page 2
Two Directors of Public Health, Dominic Harrison and Colin Cox, delivered our keynote speeches introducing the pertinent issues around advocacy.
Other activities during the day included poster hangouts, an advocacy themed graffiti wall, mentorship networking and three training zone development sessions. It proved to be an inspirational and inspiring day.
P H 1 : A D V O C A CY I N A CT I O N
A Passion for Public Health: Advocacy in Action Keynote Speakers Public Health as Advocacy for Social Justice Public Health, as a discipline and profession must be values driven. The values and meanings it holds are infinitely more important than the skills, competencies or knowledge it temporarily employs. It is the meaning and the purpose of its activity that is of most importance. At the very centre of public health values is a radical belief in equity - that ‘every single human life is as valuable as every other’- a variant of the golden rule “treat others as you would wish to be treated yourself”. Over the past five years we have seen an erosion of this value base, driven by the narrative misdirection of a pervasive and corrosive neo-liberal value system. More and more the meaning of public health is shifting. Increasingly, the assertion that the purpose of public health is to manage risk - particularly financial risk - is gaining ascendancy. From this value position the prime task of public health is not to meet social need but to assist an increasingly ungenerous state to avoid preventable costs. This corrosion of the meaning of public health endeavour leaves public health professionals as engineers maintaining a machine whose purpose is beyond their agency. If we believe that equity is an important value in a democratic society we must establish the political, social, economic, institutional, legislative, professional and cultural machinery to deliver it. In this task, public health has a unique role, one which involves making visible ‘that which is hidden’ – particularly the (literally) ‘embodied’ injustice and inequity that arise as hidden consequences of neo-liberal economic policy. We are not doing as well at it as we could be in this task, and we are disabled in various crucial ways:
The literature in public health is rich in explorations of practice, but rather poor in its dispositions on meaning. NICE manufactures ‘evidence based public health’ that explicitly excludes critical public policy NORTH WEST REGISTRARS
options – even though most public health gains have been achieved as a result of public policy change. Evidence of what might be most effective is systematically (and possibly unethically) excluded from evidence production.
Despite seeing public health as an agency of ‘change’, we are still operating our professional accreditation on a series of competencies developed in the 1970s and working to a definition of health established in the 1940s. It would not be unreasonable to describe public health as a ‘Skeuomorph discipline’. (A skeuomorph is a ‘derivative object that retains ornamental design cues to a structure that was necessary in the original’)
dissent is an integral part of its underlying structures and processes. To do this public health needs to read its evidence differently. All our knowledge is capable of interpretation on multiple levels: Literal, Allegorical, Metaphorical, Analogical. Yet we continue to read evidence of epidemiological analysis from a narrow literal perspective. We easily become entrapped in a ‘smoking causes cancer’ narrative but poverty causes twice as much smoking as being wealthy. In what sense then is cancer not caused by poverty? In saying that smoking is one of the ‘biggest causes’ of cancer are we not discounting the distal and favouring the proximal - privileging a narrative that is surely starting only half way down the full ‘causal chain’ that our evidence tells us is true and apparent. Yet we are ourselves making this evidence invisible – our narrative has been ‘captured’.
One consequence of these disablements is that the world continues to generate increasingly unequal life chances at almost every level of geography. Public Inequality is the biggest preventable health is pulled into a position where its cause of morbidity and mortality. disease based programme investments Mostly public health improvement is (smoking cessation, healthy weight metaphorically, allegorically and management etc) are simply analogically best understood as investments aimed at attempting to ‘buy delivered through a back’ the health that was movement for lost as a result of the “public health has a unique role, social justice as bad previous failure to one which involves making visible things simply don’t challenge neo-liberal non happen randomly – health sector public ‘that which is hidden’” they happen most to policy choices. the poor and As only one among many dispossessed. Public health needs to consequences, inequalities in strengthen its value based commitment health, wellbeing and life expectancy to advocacy of social justice. are systematically produced as a In this role we need to reset the equality consequence of social, political and agenda, reframe many of the principal economic systems designed to transform public health issues, develop a stronger citizens with civic rights into consumers cultural capacity for our own ‘narrative with market choice. The functions and capture’, follow the money to find out purposes of civil society are being rewho is benefiting from the externalised directed towards ensuring the effective consequences of unhealthy social and enablement of markets for employment, economic systems and work more goods and services rather than to the closely with our friends in the media to creation and assurance of the wellbeing popularise the interventions we know for all citizens. will make a difference. To fix this, public health needs to continue to develop itself as a discipline Dominic Harrison of dissent. Whilst it must exercise its Director of Public Health practice within a democratic framework to be legitimate, it must be understood Blackburn with Darwen Borough that power concedes nothing without Council demand and that public demand for change is stimulated by advocacy. Democracy can only flourish when such Page 3
A Passion for Public Health: Advocacy in Action Keynote Speakers Public Health Advocacy Advocacy is an important part of the public health function. It is also fundamentally a political process – and this has significant implications for public health practice, particularly for those of us working in local government. Learning advocacy techniques is important; equally so is learning to approach advocacy with humility, wisdom and caution. Let’s say that you’re getting worried about have to be high the impact of welfare reform profile. It does not on public have to be public.” health. We know that poverty is bad for health, redistribution is a way of tackling poverty, and you know that a lot of people have been affected by welfare reform. So what should you do to exercise humility, wisdom and caution, before starting to advocate for a change in policy?
“Advocacy does not
Page 4
It’s possible to see a sort of spectrum or continuum of responses to the challenge of advocacy. At one extreme there’s a sort of heroic, buccaneering approach – “my responsibility is to the people, and I have a duty to speak up regardless of the consequences”. And at the other is extreme timidity – “mustn’t say anything controversial or I might get into trouble”. Some of this difference is down to natural inclination, of course, but it’s modified by the political and management environment. Advocacy does not need to be high profile. It doesn’t need to be public. While operating towards the buccaneering end of the spectrum can be appropriate and effective in some circumstances, at other times what’s needed is a long game, played quietly and behind the scenes. It’s a game in which you don’t fight every fight, instead building trust and credibility so that when you do challenge things you’re taken much more seriously – or, in the words of the old saying, “he who fights and runs away may turn and fight another day”. But this can also be an excellent self-justification for inaction in uncomfortable situations. So, finally, keep asking yourself – when is silence a sensible tactical move in the long game that is public health, and when is it simply cowardice? Colin Cox Director of Public Health Cumbria County Council
Haweswater Reservoir, The Lake District
But for the moment, let’s assume that you’ve done your research and you’re convinced that welfare reform is bad for public health. In the words of the old prayer – you need to have the courage to change the things you can, the serenity to accept the things you can’t, and the wisdom to know the difference. So
Humility and wisdom – so far, probably so uncontroversial. But then we come to caution. And here we run into some very different styles of public health advocacy – and also find public health and politics bumping up against each other sometimes. Advocating against the welfare reform agenda in a predominantly deprived urban council where every single Councillor is Labour is likely to be uncontroversial. You know that the Members are going to agree with you. Doing so in an area where the politics are more complex – a relatively even split of parties where political control changes regularly, for example – is more problematic. A council officer just can’t start publicly advocating about a highly political issue such as welfare reform without running very significant risks – in particular of creating important political enemies for
the future.
Jane Kenyon, Public Health Registrar
The humility comes in accepting that others have a valid viewpoint. Start by checking your assumptions against your own politics. Perhaps your politics drive your approach to public health. Perhaps your experience and professionalism as a public health practitioner have shaped your politics. Many public health practitioners will assume that the sort of welfare reform we’ve seen in the last five years is going to be damaging to health, because it takes money away from the poorest in society, leaving them more vulnerable and having a range of material and psychosocial impacts. But others will believe that this welfare reform will be a positive force, supporting people into work – which we all know is generally good for health – and encouraging independence and self reliance. Question your own assumptions. Seek evidence where possible. You may well be wrong.
identify what you actually want to achieve, making sure it’s a realistic goal. And having done so, identify whether that is actually a high enough priority for you, given everything else you’ve got to do. Our time is precious. Let’s not waste it advocating for something we’ll never change. The government has been subjected to huge amounts of pressure and lobbying about welfare reform, from some powerful, erudite and influential voices. Will the addition of a local public health voice make the difference? Probably not. Is it worth you advocating within your own organisation for action to mitigate the impact of the changes locally? Almost certainly.
P H 1 : A D V O C A CY I N A CT I O N
Taking Action The North West Public Health Registrars’ Group Public Health Registrars in the North West have gained a reputation with our local Deanery as being a rather assertive, some might say mouthy, group. Or, to put it more politely, in the words of last year’s Health Education North West Annual Assessment Visit panel: “The leadership and contribution to the training programme shown by the trainees was impressive. They are extremely proactive and self-directed in their involvement with their training and this has led to an effective, supportive and very cohesive trainee group”. The North West Public Health Registrar Network was primarily set up as a peer support network for those training in the North West, but has grown in strength and focus over the last 3 years, increasingly taking a key role in developing and improving the quality of training. Registrars from the North West’s three training zones (Greater Manchester, Cheshire & Merseyside, Cumbria & Lancashire) come together for bi-monthly meetings, but also communicate regularly through a North West yahoo email group. We have two seats on the School of Public Health Board through which we can influence processes and systems, and advocate for changes to maintain and improve our training, ensuring that the registrar voice is heard. The network advocates for registrars on a number of issues. Often these are taken through our School Board but sometimes they require action at a national level. For example in November 2014 a group of our registrars developed a response to the document "21st Century Public Health: Organising and managing NORTH WEST REGISTRARS
multidisciplinary teams in a local government context", published by Public Health England on behalf of a group of organisations. In response, the registrars were invited to join a teleconference with the authors to discuss the issues raised. One of the key changes to the training scheme in the North West in the last 3-4 years has been the development of a 16 week registrar-led Part A revision programme. North West registrars also organise a Part B preparation course and mock exam at least once per year which is made available to registrars across the country. These programmes seem to have led to improved exam results, and the peer support for exam preparation that has also been delivered by these programmes has been particularly valued by registrars. As our role in driving developments in the training scheme has increased there have been regular internal debates about how much the Registrar network should take on, and the extent to which the training scheme should be registrar-led. A key example of this was the induction programme for registrars joining the training scheme. For the first time registrars took a lead role in organising induction activities for new starters in 2014. Whilst this was a new, additional role for the registrar group to take on we felt that it was important that new ST1s had a positive experience in their first weeks of training, and we were delighted that the 2014 induction programme was very positively evaluated.
both as mentees and mentors. Sustaining all these activities requires a great deal of commitment, time and effort from registrars across the network. It also requires the support of Educational Supervisors, Training Programme Directors and the Head of School in recognising the importance of registrar contributions to the network, and the role of these contributions in demonstrating learning outcomes. Whilst registrars put a lot of time into network activities, particularly in the middle to later stages of training, registrars also benefit greatly from this support (for example, the induction programme and in exam preparation) and this helps to sustain continued commitment and engagement from Registrars in the network. Jen Connolly & Katrina Stephens Co-Chairs North West Public Health Specialty Registrar Network
“Public Health Registrars in the North West have gained a reputation with our local Deanery as being a rather assertive, some might say mouthy, group!”
New starters in the North West are also supported by a buddying scheme which matches new ST1s with a registrar who is in a later stage of training to provide advice and support on an informal basis. We are now working to develop a more formal approach to mentoring which would start in training and see people through into their consultant careers,
Page 5
Soapbox Summaries The NHS Must Stop Promoting Misogyny Desmond Tutu once said that ‘If you are neutral in situations of injustice, you have chosen the side of the oppressor’. The NHS, through its apparent indifference to the sale on its premises of degrading materials that sexually objectify women, is promoting a culture of female oppression and, consequently, contributing negatively to many health issues and inequalities.
fathers, view breasts and breast-feeding if this is to be achieved. Low breastfeeding uptake is just one of many manifestations of how misogyny can negatively impact on health.
This huge issue needs addressing across the whole of society, but public health and NHS communities have a duty and opportunity to take immediate action. Shops in hospitals would never sell cigarettes or alcohol on a point of principle, they are bad for health and it would send out a really irresponsible message. That same principle should be applied here. The NHS is an institution that people really believe in; it is held up as setting a moral tone. Yet, apparently, the NHS thinks it “We really need to wake up to the mesacceptable to sage that is literally being sold everyday in view women hospitals across the country, that the NHS (and breasts) in a derogatory way.
Misogyny, an ingrained prejudice against women, manifests in many ways. It has become so normalised into thinks it is acceptable to view women (and The terrible everyday culture that breasts) in a derogatory way.” events that we are frequently unfolded in Mid blind to its existence, Staffordshire have and it thrives despite antitaught us that what we permit within the discrimination law. Every day, NHS, we promote. By turning a blind the media is flooded with degrading eye to this issue, the NHS is images of almost naked women, images inadvertently promoting, as well as so commonplace that, on some level, being subsidised by, misogyny. It has they affect how all of us view gendertaken the side of the oppressor. It must roles. This contributes to discrimination now take the lead in setting a new against women, women’s health, and cultural norm, one in which respect is the apparent need for men to appear paramount. Action is needed at a ‘macho’ (with resultant detrimental national level to stop shops on NHS effects on health-seeking and suicidepremises from selling blatantly behaviour). degrading misogynistic materials. This Let’s take the example of how would be a small but significant step in misogyny affects breastfeeding. It is the right direction. well recognised that despite some Mel Roche improvement, the UK struggles to increase breastfeeding uptake, Public Health Registrar particularly among the poorest communities. Qualitative studies highlight that many women feel too Reducing the Strength awkward, embarrassed or ashamed to breastfeed, especially in public. This is Harm from excess alcohol consumption unsurprising when common culture is pervasive. Issues overwhelmingly tells us that breasts are with alcohol show up primarily sex objects. While the media across the life course continually encourages the sexual from ante-natal admiration of naked breasts, the thought development, to of a woman breastfeeding a baby is felt violence, and alarming rates of by many to be rude or exhibitionist. In premature mortality from liver disease. trying to increase breastfeeding uptake, The dangers are especially great for much emphasis is placed on the England’s 1.6 million most high-risk mother’s role, but we really need to drinkers, many of whom are dependent address how wider society, including on low price, high strength alcohol. Page 6
Reducing access to high volume, high strength alcohol is an effective way of curtailing dangerous levels of alcohol consumption and FPH continues to back a minimum price of 50 pence per unit. But whilst we’re waiting for a change in the law, what else can we do? Reducing the Strength is a voluntary scheme originated in Ipswich which simply asks individual high street retailers not to sell beer or cider that is stronger than 6.5% ABV (these often go on sale for around 30p/unit). The diverse benefits that are seen with this approach make Reducing the Strength an ideal focus for Public Health advocacy in local authorities. Reductions in crime, street-begging and anti-social behaviour, plus improvements to health, and a renewed sense of responsibility amongst licence holders make it easy for partners to band together under the Reducing the Strength banner. Looking for a quick, quality win? This might just be it. Helen Armitage Public Health Registrar
Blood Pressure What's your blood pressure? High blood pressure is second only to tobacco as a risk factor for premature mortality in the UK. It's in that awkward position of being both a risk factor and a disease, and over five million adults in the UK have undiagnosed high blood pressure. Outcomes related to high blood pressure are worse in deprived groups. We need to take a system wide approach to tackling blood pressure - prevention as well as identification and improving management of high blood pressure. Jennifer Connolly Public Health Registrar
P H 1 : A D V O C A CY I N A CT I O N
Soapbox Summaries A Passion for Toilets It may be slightly unconventional to have a passion for toilets. I am Hayley Teshome Tesfaye Specialty Registrar in Public Health and toilets are my passion! Why? 2.5 billion people do not have access to adequate sanitation and 1 billion people practice open defecation. Every minute, 3 children under the age of 5 die because of dirty water and poor sanitation. That is 180 children in 1 hour. I believe that is this is unacceptable. A few years ago I lived and worked overseas, in Papua New Guinea and Ethiopia. I witnessed the impact of a cholera outbreak on a community, particularly the very young, the very old and those living with a disability. I know of girls dropping out of education because their schools didn't have a basic toilet. We know that if girls complete their education their future and their children's future will be stronger. I listened to women telling me that having a toilet in their village meant that they were safer from sexual assault. Since the millennium, great progress has been made regarding toilets however more work is required to provide universal access to basic drinking water, sanitation and hygiene. But what more can we do? ...ABC A is for awareness - Know the difference between open defecation, a pit latrine, a VIP latrine and flush toilet. B is for ‘be a poo to the loo taker' - twin your toilet at home and work for only £60 C is for celebrate - UN 'World Toilet Day' is held every year on 19th November so link into the global campaign for toilets by joining a mass squat or holding a no toilet day. Hayley Teshome Tesfaye Public Health Registrar
Domestic Violence
Building a Healthier Economy
Through a health needs assessment I have developed a real insight into the issue of domestic violence and how it impacts public health. I told “Sarah’s” story to illustrate some key issues around domestic violence: “Sarah” a 38 year old, single unemployed mum living in a deprived area of Salford, with two children “Mark” who is 16 and “Joanne” who is 15. Seven years ago Sarah left an abusive partner who regular attacked her physically and verbally often in front of her children. With the support from 'Women's Aid' she managed to escape the relationship and start a new life in another area. Everything was going relatively well when two years ago Mark started taking drugs and drinking, in addition he started becoming verbally abusive to his mum and his sister. This quickly escalated to physical attacks which left both Joanne and Sarah terrified of him. Joanne is now having regular panic attacks, is on anti depressants and is regularly truant from school and Sarah has turned to alcohol. Sarah states that Mark’s behaviour is exactly like that of his Dad’s when he used to be abusive.
“domestic abuse can be a viscous cycle which if we don't act now will continue to affect generation to generation” This story highlights two key aspects of domestic abuse. Firstly domestic abuse is not only partner-topartner abuse as the story above illustrates, and secondly, domestic abuse can be a viscous cycle which if we don't act now will continue to affect generation to generation.
In the classic science-fiction trilogy 'The Matrix', the protagonist wakes up from a world that he discovers is not what he has been taught to believe. From a public health perspective, we also need to wake up and question many of the current narratives around a key determinant of health - our economic system and policies. With such knowledge, we can influence others to think about alternatives to the unhealthy economic matrix to which we connected. For example, the way we measure economic growth (GDP) should be reconsidered as it fails to reflect social and environmental “wealth”, as well as income inequalities. Further, the constant policy objective to grow the economy has significant public health implications. For example, the current model of economic growth has brought a continuous cycle of bust and boom that impacts those who are most vulnerable during recessions and resulted in decades of rising income inequalities. A recent Oxfam report notes that 1% of the global population will soon own more than half of the wealth. Further, economic growth as we now measure it, is simply not sustainable. If everyone on the planet had the same use of resources and energy as the UK, we would need 3 earths to provide enough resources. As public health leaders, it is essential that we look at how we can advocate to our networks and decision makers to think about more sustainable, ethical and health promoting economic strategies. Darryl Quantz Public Health Registrar
I challenged the group to find out what their local authority is doing to address domestic abuse and think of one action they could take to support the agenda. Jon Hobday Public Health Registrar
NORTH WEST REGISTRARS
Page 7
Soapbox Summaries Vaccines – Problem?
What
is
the
Vaccine hesitancy is on the rise. Half of people now admit to having doubts about vaccines compared to less than a fifth over a decade ago while a third think there are too many vaccines. We are lucky to live in a country where vaccine preventable diseases are now rare and many have forgotten that these diseases cause death, disability and serious illness. Instead they often fixate on vaccine safety. Public health cannot be complacent about vaccine refusers and hesitants as the large outbreaks of measles in the UK and USA have shown. We must not be afraid of asking the question but we must come prepared with answers. Emma Savage Public Health Registrar
Health Impacts of Air Pollution
“Globally…around 3.7 million deaths each year occur as a result of outdoor (ambient air pollution)”
But what about closer to home? Within the UK there are statutory thresholds to protect air quality. Except that there are no safe limits and health effects occur at levels far below threshold levels. These health effects account for at least 28,000 premature deaths each year in the UK, mainly from cardiovascular disease, respiratory disease and cancers. The health effects of air pollution are cumulative, and impact on the entire population. However some groups, such as children, and those with underlying disease, are more vulnerable. Air pollution presents an unacceptable health inequality, as those experiencing disadvantage are more likely to live in areas with higher levels of air pollution, and are more vulnerable to its effects. We know that increasing car use is playing an increasing role in air pollution – but how can we effectively tackle this problem? Charlotte Smith
I believe air pollution is a key Public Heath priority, and I would like to explain why. Globally around one in eight deaths can be attributed to air pollution. Many of these deaths are related to indoor air pollution, but around 3.7 million deaths each year occur as a result of outdoor (ambient air pollution). Air pollution is a major cause of climate change, contributing to the ‘green-house effect’ responsible for global warming, rising sea levels and increased extreme weather events globally. Ambient air pollution is largely the result of burning fossil fuels and industrial processes. It is manmade, and is usually associated with rapidly industrialising nations; evident in the smog visible in many cities around the world. Page 8
Public Health Registrar
Diabetes Prevention Programme Undertaking a placement with the Reducing Premature Mortality team in NHS England has provided me with the opportunity to work on developing the new national Diabetes Prevention Programme (DPP). The DPP is a joint programme by NHS England, Public Health England and Diabetes UK and aims to ensure that those who are at risk of developing type 2 diabetes are identified early and referred into lifestyle intervention (diet and exercise) programmes. Based on current trends it is likely that 4 million people in England will be living with diabetes by 2025. Treating diabetes and its complications already account for about 10% of the annual NHS budget. Randomised control trials conducted in China, Finland, USA, Japan and India have documented 30 to 60% reductions in incidence of type 2 diabetes in groups receiving intensive lifestyle interventions compared with those in control groups. The DPP aims to make such interventions available to people at high risk of developing type 2 diabetes across England. Katrina Stephens Public Health Registrar
Reducing Loneliness Die Young, Stay, Er, Invisible? Professor Chris Hatton’s soapbox was about people with learning disabilities and how we, as a public health community, relate to them and support them. He wrote about his soapbox experience on his blog which you can access here. Professor Chris Hatton Lancaster University
I would like to start by sharing the story of Whale 52. Whale 52 is blue or a fin whale, or possibly a hybrid of the two. He lives in the pacific. Like all male whales, he sings when is looking for mate. Although no one has ever seen whale 52, hence the confusion over his exact species, scientists have for 20 years been able to track him around the ocean. They can do this because while other whales sing at 17 or 18 hertz, Whale 52 uniquely, communicates at 52 P H 1 : A D V O C A CY I N A CT I O N
Soapbox Summaries hertz. He broadcasts quite literally on a different wavelength. It has been suggested that he may be deaf; it is also possible that other whales can hear him but they don’t understand him. Either way they never respond. Whale 52 has no friends and has been described as the loneliest whale in the world.
“Loneliness is an important public health issue because it is a significant risk factor for a wide range of mental and physical health problems” I don't know the prevalence of loneliness in the aquatic world but for humans it is estimated that 6% of people feel lonely all or most of the time. In the under 25s and over 55s almost 1 person in every 10 feels lonely. There are also many groups who experience even greater rates of loneliness, such as the very old where nearly half of all people over the age 80 report being lonely. Other at risk groups are people who are widowed, divorced, unemployed and people living with debt. Loneliness is an important public health issue because it is a significant risk factor for a wide range of mental and physical health problems. This includes depression, high blood pressure, sleep problems and reduced immunity. Lonely people are reported to be almost twice as likely to visit their GP as patients who are not lonely and are more likely to visit A&E departments. The protective effect of having adequate social relationships is thought to be equivalent to quitting smoking. But there are things we can do! Liverpool Public Health Observatory published a rapid review on loneliness in 2014 and whilst the evidence base still needs developing they recommend a number of actions. This includes supporting schemes such as befriending programmes, community navigators, mentoring and targeting work to make sure we reach the most vulnerable. More broadly loneliness should be considered in all policy areas such as transport and housing. We need to make sure Health & Wellbeing Boards NORTH WEST REGISTRARS
recognise the impact of loneliness on health to prioritise and join up actions. In times of austerity I think it is really important we don’t think of reducing loneliness as an outcome that is merely added value of a policy or an activity and something we can do without. For anyone concerned about whale 52 there is a campaign to fund a 20 day expedition to search for him – so hopefully we learn to understand him better and let him know someone cares. Chris McBrien Public Health Registrar
Double Trouble? It is well recognised that multiple pregnancies are high risk (NICE clinical guideline 129) and that many multiple birth families experience their children having to be cared for in NICU. But what happens when you get home from the hospital with your new babies 2, 3 or more and shut the front door? I brought some props with me to help demonstrate…some of my daughters’ dolls. I asked a colleague if she wouldn’t mind holding a baby as if she was breastfeeding (done – easy!), I then gave her baby number two (manageable, but slightly more complex!), then I gave her baby number three (where would that one go?! …to a colleague sitting next to her), and then baby number four (??!!! well that one went to the colleague on the other side!). I asked her how she was feeling – the answer was slightly overwhelmed! The problem for many multiple birth families though is that support to help them with managing the feeds, the changes, the crying, the cost isn’t sitting right next door. Mostly parents of multiples hear the well worn out phrase ‘I just don’t know how you cope’; and unfortunately for most multiple birth families this includes the professionals too. Most healthcare professionals know little or nothing about the problems
facing multiple birth families. Comments like ‘gosh I’ve never seen that before…’ when a Health Visitor sees a new mum breastfeeding two hardly leaves the mum feeling supported. In reality many don’t know how to support a mother to breastfeed two (rugby hold works well, though using a proper breastfeeding pillow makes a world of difference!) or fully understand quite how difficult it is to manage more than one baby at a time. The lack of knowledge amongst healthcare professionals about multiples means that these families often do not receive the level of support they need, when their babies are new or indeed during the rest of those formative preschool years. In fact, there are no specialist health visitors in England, Wales or Scotland for multiples and only one in Northern Ireland, who is part of a trial being supported by the Twins and Multiple Births Association (Tamba). Instead support comes from local twins clubs, other parents of multiples and national charities like Tamba. But these families need more than that. Mothers of multiples are twice as likely as mothers of singletons to develop PND (around 20%). In addition to this the financial burden is huge – it is estimated that it costs £1,200 per month to raise twins and more for parents with triplets or more (and 50% of multiple birth families have at least one other child). Unsurprisingly, relationship breakdown is common – with double the incidence amongst couples with multiples compared to singletons. Many families feel they are simply on a rollercoaster from one feed to another, one nappy change to another (…about 105 of them a week for twins!); stress and lack of sleep become normal! But this isn’t ok. As public health advocates we need to raise awareness amongst healthcare professionals so they begin to learn more about the difficulties facing multiple birth families. And remember, next time you meet a mum with twins or more, please don’t say ‘gosh I don’t know how you cope’…because she might just tell you!! Anna Varela-Raynes Public Health Registrar
Page 9
Soapbox Summaries Creating Money to Defend Health Imagine you had the power to create money. Think what good you could do with that power; the ability to create purchasing power and be the first to benefit from it. Think of the great changes you could make to public health. Now tell me, do you know who we have given this power to in the UK? Who creates all that money? You might think the Bank of England creates money, but in their own words, they only create around 3%. Here’s what they have to say about the other 97% of it: “in the modern economy,… bank deposits are mostly created by commercial banks themselves… Commercial banks create money, in the form of bank deposits, by making new loans. For this reason, some economists have referred to bank deposits as ‘fountain pen money’, created at the stroke of bankers’ pens when they approve loans” Bank of England Quarterly Bulletin, 2014 Q1, p2-3 We have given the power of moneycreation to banks, and they lend it back to us at interest.
The creation of most of our money as debt creates socioeconomic inequality by sucking wealth from the have-nots to the haves – the rich get richer and the poor get poorer. Solutions that do not address this root issue will never achieve sustainable wealth redistribution, or reverse socioeconomic inequalities in health, because they are trying to make water flow uphill – we need to change the hill. The lobbying group Positive Money are campaigning to make money-creation more accountable and constrain the power of the banks. Their success has the
Page 10
potential to level inequalities on a scale never imagined. " Banking was conceived in “ iniquity and was born in sin. The bankers own the earth. Take it away from them, but leave them the power to create money, and with the flick of the pen they will create enough deposits to buy it back again. However, take away from them the power to create money and all the great fortunes like mine will disappear and they ought to disappear, for this would be a happier and better world to live in. But, if you wish to remain the slaves of bankers and pay the cost of your own slavery, let them continue to create money." Sir Josiah Stamp (1880-1941), former director of the Bank of England Matthew Saunders Public Health Registrar
Learning from experience overseas: From needs to gaps to assets I trained in Community Medicine in the Sudan before public health training in the UK. In both these, the training relied so much on needs assessments, that I found myself subscribing to a needs led model of public health. When we think of Africa, we cannot help but think of need – famine, poverty, literacy levels, and so on. Then I went back to work in the Sudan for three years where I led three national strategies. I learnt from these that needs assessments are not enough; especially in a resource constrained setting. We have to consider what is already there to identify the gaps; the priorities derive from the gap analysis. So I learnt that, while we should consider needs, we must take this further to consider gaps. The gap analysis should drive our strategies. Then I reflected some more, and realised that I actually learnt more than I realised… We should not just be looking at gaps. We should be looking
at “The greatest asset of assets. I think communities is their people” UK communities can learn so much from Africa especially in an economic recession. For example, communities in Sudan have withstood four-fold price hikes within a few years. The scale of challenge and need is so much more in developing countries; yet people survive and innovate. So how can that be? I realised that the greatest asset of communities is their people. The people you meet and work with in developing countries are survivors. They are resilient. They support each other. One does not go to sleep with a full belly while a neighbour is hungry. They are creative in using resources and sharing resources. Economic problems demand economic solutions. In developing countries, we have seen the growth of microfinance for poverty reduction, women in small communities operating a revolving fund that loans to each woman in turn at 0% interest, the Grameen bank in Bangladesh, and the first bank based entirely on mobile in Kenya (Safaricom M-Pesa for mobile money). So now, I am advocating for these economic solutions, and for community resilience through people development. Creativity and resilience are the greatest assets within people; and that is the starting point for development. If you are interested to get your own learning from overseas, the Faculty Special Interest Groups will be a good place to start. The Sudan Health Consultancy Group, Public Health Africa, India, Pakistan and other groups are all linking in with Faculty Global Strategy. If you are interested in a particular country, it is quite likely there are International Faculty members based there; and others in the UK who share your interest. If you would like to know more, I would be very happy to advise. Dr Muna I Abdel Aziz Consultant in Public Health Warrington Borough Council & FPH International CPD Adviser (Formerly, Deputy Director of the Public Health Institute Sudan, 201013) P H 1 : A D V O C A CY I N A CT I O N
Soapbox Summaries Let there be Light – Making Sight Loss a Public Health Priority The eye is the most important sensory organ with 80% of all sensory impressions coming from the eye (National Institute for Health, 2008). In the United Kingdom, 2 million people (3% of the population) are living with visual impairment, with a potential increase to 4 million by 2050 (Access Economics, 2009). People living with sight loss are at increased risk of poor health, early death, reduced quality of life, social exclusion, unemployment and poverty. A key opportunity for public health intervention is the fact that 50% of sight loss is preventable through primary prevention or by proper management of the underlying condition (Access Economics, 2009). Early reporting of symptoms is essential to improve outcomes in many conditions. This key component of secondary prevention can be greatly affected by sight loss. For instance, early detection of cancers heavily relies on sight. The ‘Be Clear on Cancer’ campaign advises visiting the doctor for any of the following: "blood in stool", “blood in urine", "unexplained weight loss", "swelling of the legs", and "a new mole or a change in the appearance of an existing mole …". It is likely that some visually-impaired people will present late for diagnosis and treatment of cancer. It is essential, therefore, that public health campaigns are inclusive for visually impaired people. Care pathways, especially primary care, should also recognise the limitations of visually impaired people to observe early signs of disease and facilitate early presentation. There are a number of useful resources to improve care for people living with sight loss. The Sight Loss Data Tool produced by the Royal National Institute for the Blind, provides information on sight loss at a local level including estimated number of people living with sight loss, a change forecast, and the level of services for people living with sight loss. This tool can
NORTH WEST REGISTRARS
inform the Joint Strategic Needs assessment, fundraising, advocacy, marketing and communications, as well as service and strategic planning. The UK Vision Strategy 2013-2018 seeks to make eye health a public health priority through “research" and "sound data collection". It also aims to "Integrate eye health and sight impact into major public health and education drives, similar to smoking, diet or obesity" through ongoing, targeted, evidence-based campaigns. The Adult UK sight loss pathway supports “Seeing it my way” - QOF (quality and outcomes framework) for blind and partially sighted people. Its objectives include: Early Interventions, Visual impairment Rehabilitation to optimise functional vision and Appropriate Community Care. Olukemi Adeyemi Public Health Registrar
The Importance of Community Development (Or why despite being called “public” health do we not work with the public more often?)
undertake a qualitative dissertation. I went and spoke to young mothers from the most deprived areas of Sefton. Their life stories, opinions and experiences brought to life the statistics I had looked at related to teenage pregnancy and its links to poorer long-term health outcomes for their children. These young women were fighting to contradict these statistics and build better lives for themselves and their children. Their lives and stories had clear policy and practice implications (further information can be found here). However, this experience was often contradicted by what I observed during my work in public health. We often focus solely on statistics to tell us about population needs and during partnership work often involve everyone except the public (who are bottom of the list and often consulted only as an afterthought). I try to remember to get out of the office and to talk to local people. This can be difficult and challenging but provides good practice in selling public health ideas and principles and also raises the profile and recognition of the value of public health among local people. There are also brilliant people called community development workers who have a wealth of experience in this field. I would encourage you to go and talk to them (if you haven’t already) to find out about what is going on locally.
I am from a medical background where whether you like it or not you engage with the public every day. When I moved into public health, and became office based, one of the main things I missed was this daily interaction with patients. Then during the MPH we had a lecture on community development from Professor Margaret Ledwith. She talked passionately about community based and community led action leading to positive change. I liked it so much I bought the book. I was moved by this idea of people power and the potential positive impact this can have on people’s health and wellbeing. My MPH was quite a journey of discovery for me – I watched my positivist medical paradigm crumble and despite my love of numbers and nice graphs decided to be brave and
Halton Alcohol Inquiry Group Recently I have been involved in two projects that have been really positive. The first has been working with a local group of carers for people affected by alcohol or drug misuse to successfully bid for Public Health England funding to set up a recovery “dry” café in Halton. The second has been to support the running of the Halton Alcohol Inquiry delivered by Our Life a social enterprise who are experts in community engagement. We are dealing with wicked and complex public health issues in a time Page 11
Soapbox Summaries where funding is being reduced. We cannot hope to tackle issues such as alcohol misuse, obesity or child poverty without taking the public with us, listening to their solutions and empowering them to make meaningful changes to their local communities. My challenge to you is to get out of the office and talk to, and listen to, local people. You might just learn something! Elspeth Anwar Public Health Registrar
My Public Health Passion for Cycling Keen advocates for cycling can sometimes be guilty of making sweeping health claims for the “The bicycle is the benefits of most civilized cycling. Well, if we got conveyance known to everybody on man”. their bikes it wouldn’t solve Iris Murdoch our obesity issues on its own but, on the other hand, it is surely no coincidence that ‘cycling nations’ like Denmark and the Netherlands have half the rate of obesity that we have in the UK. As a public health advocate however, I think it is very important that we make a wider case for cycling to improve population health. This is not about middle-aged white men trying to be boy racers in lycra on expensive carbon fibre road bikes (ok, maybe I do do this at weekends). Cycling can and should be accessible
Bicycles, Manchester City Centre
Katrina Stephens, Public Health Registrar
Page 12
to all – just visit Amsterdam, Copenhagen … oh and Cambridge – as a cheap, environmentally-friendly way not just of taking exercise, but from getting from A to B and joining up communities. Yet the built environment in England does its very best to discourage us. Cities built for cars. Public buildings with no facilities for visitor cycle parking (don’t lock your bike to our railings). Shopping areas with no or inadequate cycle stands. Practically zero protected cycle lanes. Poor route signage – some of us would like to travel longer distances by bike. Courts that give motorists lenient sentences and claim that we contribute to our own demise if we choose not to wear a helmet or fluorescent yellow. By the way, check out the Netherlands again to see that everyone just wears their everyday clothes to cycle to work or to the shops. And have you ever tried to book your bike on an English crosscountry train?! Cycling is important as it’s one factor in addressing climate change, in reducing air pollution, in helping us to be physically active as part of our daily lives, in connecting us up to the world around us (how bad is sitting in a metal box all day for disconnection), in supporting our mental wellbeing. Public health practitioners should advocate transport planning which involves cyclists and cycling solutions. New builds must include safe cycle storage and parking. We need to make it easier and safer for children to cycle to school. Rail (and bus) companies must do better to offer integrated travel options. We need to make car driving the most expensive way of travelling to city centres (the ‘war on drivers’ … oh please). 20 mph limits should be imposed in built up city streets. Tougher
restrictions on lorries in rush hours. And the courts must take a much stronger position on drivers who are responsible for road deaths. For the time being cycling on roads in England can be dangerous. But it doesn’t need to be and the health benefits far outweigh the risks.
“When I see an adult on a bicycle, I no longer despair for the human race”. HG Wells.
Robin Ireland Chief Executive Health Equalities Group
Sharpening the Public Health Teeth The new public health world was designed to more effectively improve and protect the public’s health. Local authority existing regulatory functions protect health. Are public health and regulatory functions best aligned to improve health outcomes? Halton saw a need for stronger links between Public Health, Environmental Health and Public Protection to improve health outcomes. Wider public health and public protection functions were transferred into the core public health directorate, including Environmental Health, Trading Standards and health improvement teams with associated commissioned services. This aligned priorities, workforce and budgets across a range of issues: tobacco control; alcohol: workplaces; mental health; cancer; pollution; older people; health checks, physical activity; healthy weight; planning etc. to achieve joint outcomes. Embedding the regulatory functions within the core public health teams created positive outcomes:
Strong united voice within Authority across all public health issues; single accountable structure
P H 1 : A D V O C A CY I N A CT I O N
Soapbox Summaries Better aligned to work across the range of wider determinants and improve outcomes across the public health, adult social care and children’s outcome frameworks. Using the regulatory powers to promote, protect and change health and behaviour adds weight to the public health voice. Sarah Johnson Griffiths Consultant in Public Health Halton Borough Council
Healthy Infant Weaning
Halton Borough Council’s poster presented at The Faculty of Public Health Conference, June 2015
Traditionally in the UK early weaning has been the norm, however guidance “What parents really has changed as want to know is evidence has ‘when is the right emerged that early time to wean’?” weaning can increase the risk of childhood obesity, respiratory illness and allergies.
Recruited an EHO for workplaces: undertake regulatory functions alongside health improvement. Developing healthy workplaces within local businesses
Over the last 20 years the recommended age for weaning has changed from three, then to four months, before the World Health Organisation introducing the recommendation in 2001 that:
Joint tobacco control role: smoking cessation, health improvement, enforcement activities aligned across whole community and all ages
Babies should be exclusively breastfed for the first six-months
Innovative Scams Project: working with victims of Scams, change behaviour, develop resilience, reduce isolation, improve mental health.
Complementary foods: Ideally should be introduced at about 6 months of age Can be introduced earlier but not before 4 months of age
Halton is one of the few (if not the only) Authorities to merge Public Health, Environmental Health, Trading Standards and Health Improvement Functions under one Public Health and Protection team.
What parents really want to know is ‘when is the right time to wean’? Unfortunately there is no clear answer. Professionals will say it depends on the individual child, but how does a first time parent know when the right time is when they’ve got nothing to compare it to? How hungry is too hungry? How ‘interested in food’ is interested enough?
It has developed a better understanding of what public health is within the council and is one point of contact for the public to identify with.
Many mums also struggle to understand why we advocate weaning at 6 months, yet professionals accept weaning from 4 months? In both
Aligns Public Health, social care, children’s outcome framework activity
NORTH WEST REGISTRARS
social and professional circles I’ve heard mums express feeling of guilt and failure if they’ve “given in” and weaned their baby before 6 months. I’ve heard others worry they may be harming their baby by weaning early, even if they have weaned on professional advice – their perception being that the 6 months guidance must be there for reason? Could they be inadvertently making their child “fat” or risking allergies or illness? But then the confusing message regarding weaning at 4 months is reinforced when you look in the baby aisle in supermarkets – there’s yogurts, pureed jars of food and even fruit juices that state ‘suitable from 4 months’. Are these adding to the confusion – it must be okay if the baby food says so, surely? We should have support and guidance in place to ensure parents feel confident as they wean, not confused! They should know where to turn if they have questions or concerns, and shouldn’t feel guilty for trying to do the right thing for their baby. Personally, I believe parents need clearer, more explicit weaning guidance, and that the guidance needs to give one clear message that’s reinforced by professionals and the food industry. I also believe the provision of weaning support cannot be a one-off event, we need to provide ongoing support and information to ensure parents are weaning healthily. To me this seems such an important window of opportunity to influence not only the future health and eating habits of the child, but potentially an opportunity to encourage healthy eating for the whole family. This is our opportunity to improve the health of the next generation, what can you do to support this cause within your local area? Kristina Poole Public Health Registrar
Page 13
Soapbox Summaries Public Health Palliative Care Having had a keen interest in palliative care as a student, and then during my time as a junior doctor, I initially assumed that choosing to pursue a career in public health would mean closing the door on that particular passion. Working at the population level initially seemed very far removed from the patient-centred, holistic, individualised methods that embodied end-of-life care. In a field that focusses on prevention, and early intervention, it can be easy to think that by the time someone is dying, the opportunity for public health to be involved is long gone. However, I soon realised that so many of the concepts that are fundamental to public health loom large in palliative care too. Evidence-based practice is crucial, when we have only one opportunity to deliver end-of-life care well, there is an imperative to ensure that what we are doing is based on the best-available knowledge, and that we continually take the opportunities to learn. I have learnt about the concept of health-promoting palliative care, inspired by the idea that individuals with chronic progressive diseases should be supported not just to die well but to live as well as possible, for as long as possible. This idea also moves beyond the individual to consider how good palliative care can have a positive impact on family, friends, carers and healthcare workers too. The widereaching nature of grief, and our ability to cope with death as positively and
openly as possible has clear implications for the health of large numbers of our population. Health economics is also a fascinating area in palliative care, with a recent report by the Nuffield Trust (commissioned by Marie Curie) finding that an end-of-life home based nursing support service was likely to result in lower costs overall, fewer days in hospital, and a greater proportion of people dying at home (Georghiou & Bardsley, 2014). With an increasingly aging population, high levels of comorbidities and chronic disease, how to deliver good palliative care in a cost effective way is going to be a key future concern. For me, though, the starkest issue is that of inequalities. Provision of palliative care varies vastly, by diagnosis, age, ethnicity, relationship status, socioeconomic group and geography. In a recent report, the data (which has recognised limitations) highlighting that spending, per person on specialist palliative care services was estimated to have a 30-fold variation, ranging between £186 and £6,213 depending on geographical location was particularly disconcerting (Dixon, King, Matosevic, Clark, & Knapp, 2015). While my initial passion for palliative care centred around looking after people, and their families, well at the end of life, it was built upon a set of values about the importance of dignity, respect and compassion irrespective of whether someone could be cured, and was borne out of an understanding of how important it is to provide good
River Mersey, Stockport
Jennifer Connolly, Public Health Registrar
Page 14
palliative care for patients and those that surround them, whatever someone’s diagnosis, background or social situation. Public health practice may give me a different perspective on the issues, but the values I hold are just as intrinsic to this specialty, and I look forward to pursuing my passion in my career ahead. Katie Smith Public Health Registrar ‘Exercise - The Miracle Cure -
Are You a Role Model?’ Are you active every day? Do you manage to be active for 2 1/2 hours a week? Are you a role model? The evidence is overwhelming; being physically active is good for your health. Regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease and other common serious conditions – reducing the risk of each by at least 30%. It's a miracle cure! If a medication existed that had a similar effect, it would be regarded as a ‘wonder drug’. Around one in two women and a third of men in England are damaging their health as a result of a lack of physical activity – is that you? I believe that the only way to move away from our sedentary culture is a social revolution, the 5th wave of public health as Dominic mentioned this morning - shifting the whole population into a lower risk category, benefiting more individuals than shifting high risk individuals into a lower risk category An Australian study published in the WHO bulletin concluded that if all women with BMI ≥ 24 reduced BMI by 2 points (approximately 5.5 kg), the incidence of hypertension would be reduced by 12% and the incidence of diabetes would be reduced by 23%. Closing the “energy gap” by 200 kcals per day through an additional 20 minutes of brisk walking and reducing energy intake by 100 kcals (the equivalent of one chocolate biscuit) every day). P H 1 : A D V O C A CY I N A CT I O N
Soapbox Summaries We’ve all spent time in meetings discussing how we can persuade people in our communities to be more physically active. But are you sitting round that table as someone who includes activity as part of your day? We’re all influenced by other people – community leaders, celebrity figures and our peers. If you’ve read Malcom Gladwell’s book Tipping Point you’ll understand that Mavens control word of mouth epidemics. They need knowledge and skills to start epidemics but it's not so much what they know but how they pass it along. If we all went out from here, with a belief that by fitting physically active
moments into our day, we could enthuse others around us and they in turn impact wider, then we may, just may, spread health like a virus into our communities, reducing the impact of chronic disease on individuals, families and health and social care services, and it's free!
"Everybody active every day" "physical activity, the miracle cure ".
-
Dr Vicci Owen-Smith Clinical Director of Public Health NHS Stockport CCG
What does it take? Well, two ten minute walks a day, every day. That’s parking a little further from work, using the stairs, taking a 10-minute walking break. Colleagues in Stockport in one department have started a competition on climbing stairs. And within a few days, they're coming to me saying how great they feel? That's all it takes!
Manchester Cathedral
Katrina Stephens, Public Health Registrar
Longsleddale Valley , The Lake District
Jane Kenyon, Public Health Registrar
Jodrell Bank, Cheshire
© Cheshire East Council
NORTH WEST REGISTRARS
Page 15
Advocacy in Action Interview with Andrea Crossfield, CEO of Tobacco Free Futures Tobacco Free Futures is a social enterprise, supporting regional and national tobacco control activity at a local level. They offer consultancy, training, managed programmes and high quality campaign resources that enable Local Authorities, Directors of Public Health, and other organisations to tackle tobacco issues in their area. Andrea is Chief Executive Officer of Tobacco Free Futures and has led the organisation since it was formed as Smokefree North West in 2008. She has led the organisation in the transition into a social enterprise from April 2013.
We set up Tobacco Free Future (initially as Smokefree North West in 2008) with the support and leadership of North West Directors of Public Health and the NHS. We did this because we had a belief that we could turn off the tap of new young smokers in the North West and end an intergenerational cycle of smoking in our communities. We invited a senior figure from the Californian tobacco programme to the region to share their learning and experiences as one of the world leaders in tobacco control and put in place a programme based on that successful blueprint (more information is available from CDC and TobaccoFreeCA).
Andrea is actively involved in the Smokefree Action Coalition and “Advocating nationally for the has a keen interest in public health business case for pregnant advocacy. She believes the success of the tobacco control advocacy women to have access to movement can provide lessons for good practice for future partnership incentives to quit has been a key work to tackle wider well-being advocacy role for us” agendas. Andrea was awarded an MBE for her contribution to public health and tobacco control in the North West in the 2015 New Year’s Honours list. One of our registrars, Jennifer Connolly, had the opportunity to ask Andrea a few questions to find out more about the work of Tobacco Free Futures, and potential learning and opportunities for registrars to develop their advocacy skills. What first drew you to working on tobacco control? I was working in environmental health in Liverpool early in 2004 and an exciting opportunity arose to become involved in SmokeFree Liverpool and driving forward a local smokefree law. Liverpool's local smokefree legislation helped achieve the comprehensive national smokefree law that came into effect in July 2007. Working as part of the Smokefree Action Coalition to achieve this was an intense, hugely rewarding experience and I saw that there was so much more to be achieved in tobacco control. I understand that you’ve been leading Tobacco Free Futures from when it was first established, how have you gone about leading and developing an organisation like this? Page 16
Working in partnership has been key to developing the organisation and its success; whether through building the organisation with local Directors of Public Health, learning and sharing with international expert colleagues, working as key members of the national Smokefree Action Coalition or working alongside local elected members to achieve our shared ambitions. How do you work with local public health teams? We work alongside local public health teams, working in partnership, providing leadership and delivering results. Tobacco Free Futures has established a respected track record and reputation locally, in the North West, and nationally, delivering ground breaking and award winning programmes and campaigns which are driven by evidence based research and public insight. We are working to create communities in which tobacco becomes less desirable, less acceptable and less accessible. Congratulations on your recent MBE award for your contribution to public health and tobacco control! How did it feel to have your work acknowledged at this level? The MBE was a lovely surprise and recognition of what we have achieved together in the North West. Making smoking history for children is my passion and Tobacco Free Futures award winning campaigns and
programmes have contributed to a dramatic drop in youth smoking prevalence rates with 14 year old prevalence at 5% now; over 70% lower than it was when we set up in 2008 (according to TSNW data). There are also 20,000 fewer adult smokers in 2013 than in the previous year based on national data. Can you describe the sort of advocacy work that Tobacco Free Futures undertakes? Tobacco Free Futures has empowered more than 120,000 adults and young people in the North West to have their say on Department of Health tobacco consultations in 2008 and 2012. It has engaged communities across the region in our vision of a smokefree generation. We work as a core member of the Smokefree Action Coalition to reduce the harm from tobacco by ensuring that an effective, fully funded comprehensive tobacco control strategy remains a central element of government health policy. Could you describe the inequalities in tobacco use, and related morbidities and mortalities, as a result of socioeconomic inequities that you're aware of from your work? The more deprived you are, the more likely you are to smoke. Almost every indicator of social deprivation, including income, socio-economic status, education and housing tenure, independently predicts smoking behaviour. Consequently individuals who are very deprived are also very likely to smoke. These differences in smoking behaviour translate into major inequalities in illness and mortality accounting for at least 50% of preventable deaths. As smoking prevalence is highest in the population groups least able to afford to smoke, smoking deepens deprivation, social inequalities and child poverty. Smokers from disadvantaged backgrounds are also more likely to die or suffer injury from smoking-related fires. Gruer’s 28 year cohort study (BMJ 2009) found that among both women and men, never smokers had much lower mortality rates than smokers in all social positions. Smoking itself was a P H 1 : A D V O C A CY I N A CT I O N
greater source of health inequality than social position and nullified women’s survival advantage over men. This suggests the scope for reducing health inequalities related to social position in this and similar populations is limited unless many smokers in lower social positions stop smoking. Do you have an advocacy role in addressing those wider determinants? People in lower socio-economic groups who smoke are just as likely to try to quit as affluent smokers but are less likely to succeed. Their lower success rate is partly due to stronger nicotine addiction. In every age group, smokers from deprived backgrounds take in more nicotine than more affluent smokers, even when the number of cigarettes smoked is the same. It is essential that more addicted smokers have access to high quality local stop smoking services. Tobacco Free Futures’ programmes like the Supporting a Smokefree Pregnancy Scheme have focused on providing additional support to pregnant women at high risk of relapse of smoking, living in poorer communities where smoking rates are higher. Results have been outstanding with 69% of women quit at 4 weeks and 51% of those still quit at 12 weeks post-partum. Advocating nationally for the business case for pregnant women to have access to incentives to quit has been a key advocacy role for us within the national pregnancy challenge group set up by PHE. What’s been your biggest success to date? Achieving legislation on standardised packaging and smoking in cars with children in the last Parliament was a huge success, but actually when we look at the objectives set out in the 2008 ‘Beyond Smoking Kills’ report, they have all almost all been achieved which is amazing. ASH will be publishing its new report “Smoking Still Kills” in June. I hope we can achieve the same level of success in fulfilling the ambitions set out in that report. When we do then we will truly have made smoking history for all our children in
Andrea Crossfield © Tobacco Free Futures
the North West. What top three tips would you share for registrars wishing to undertake advocacy work? Act with people, purpose and passion in mind Build your case on solid, peer reviewed evidence. If it isn’t there yet, build the evidence. Create your key message(s) and equip as many messengers as possible How can public health registrars become more involved in the work of Tobacco Free Futures? We would love to have the opportunity to provide public health registrars with public health advocacy experience through a placement with us. The Deputy Director of the UK Centre for Tobacco and Alcohol Studies, Professor
Ann McNeill sits on our Board and we’re keen to explore research project opportunities including with data held from existing evaluations. There are opportunities to work locally and nationally. Get in touch if you’d like to explore how we might work together. To find out more about Tobacco Free Futures, or to get in touch with Andrea and the team, visit Tobacco Free Futures. Jennifer Connolly Public Health Registrar
Thank you The North West Editorial Team (Anna Varela-Raynes & Matthew Saunders) would like to thank everyone who has contributed to this edition of PH1 and especially to those who shared their fabulous photos with us. NORTH WEST REGISTRARS
Page 17