Public Health in Local Authorities: One year on (Alan Page 14.04.14)

April 1st saw the first anniversary of the reintegration of public health back into local authorities. There was concern expressed prior to the move from sections of the media (Hetherington 2012) and inevitable concerns from those within the Public Health units of the NHS about the future.

So where are we 12 months on?  Well the answer is mixed. There is concern expressed in a report by the Royal Society of Public Health (2014) that over half (52% of Directors of Public Health, public health consultants/specialists and health improvement practitioners) are unconvinced that the move to local authorities will aid in public health in the short term, whilst 75% were hopeful that the historic skills of LAs to engage with the residents will aid in future improved delivery. What I found the most revealing through was that 59% of respondents felt that health decisions were being based on a political basis rather than on evidence. Welcome to the swamping world of local authority decision making. Their response is that 80% feel they need better influencing skills, something we as EHPs might learn from.  At a time of decreasing budgets the politics of competing budgets are only likely to increase.   On the other side of this debate is John Middleton the outgoing DPH for Sandwell who suggests the move back to LAs returns public health to where is belongs with LAs able to “weave public health into local government tapestry” (Bindle 2014) with investments in leisure, social housing, market gardens as clear public health functions.  Of course my favourite part of his piece is that he states “public health money ….. could justifiably be diverted into food safety inspection if those inspections also looked at salt or trans fats content”, something already picked up by a number of councils.

The RSPH respondents did though make an interesting point about the type of evidence that is available highlighting that much of the existing data around public health related to savings to the NHS and not savings to LAs. Of course this is interesting to EHRnet which is trying to foster research within the profession and this latter point should of course be built into our future research and I would suggest will be easier than showing direct savings to the NHS budget.

Of equal import is the concern raised by Iacobucci (2014) in which he points to the fact that the ring fenced public health budget is being used to prop up other services; that staffing in some regions were being reduced; and that the public health workforce is spread too thinly. I take issue with some of these comments since many roles within local authorities have their basis in public health and welfare promotion.  It can be argued that the resources for public health have grown with the move to LAs and that a new vision of the public health workforce needs to be developed.  The report points to money being deployed to domestic abuse services, leisure services and housing all of which have a clear public health dimension.  Indeed PHE has defended the use of monies used in this way (ibid).  I do understand the concerns over monies being removed from substance misuse, sexual health, smoking cessation, and obesity interventions, but in light of local priorities can it be shown that these are the key priorities for the area?   I attended a county PH development meeting last year and I am honest in saying I was surprised that the DPH was suggesting a status quo plan for spending money on priorities brought from the NHS with no thought of wider public health interventions.

One the other side of the developing turf war is the LGA who has questioned the whole idea of a ring fenced budget (Dunton 2010).  More worrying is the view of Jongsma (2014) who points to a recruitment crisis in public health medicine with only 12% of those surveyed (n=590) thinking there will be enough PH consultant posts to serve the population in 10 years time, only 36% thinking their role was understood; and that medical professional are less willing to work for LAs in light of LAs not valuing their skill set and potentially employing non medical professional due budgetary restrictions.  However the figures are called into question by Gamsu 2014 who provides a very useful critique of the debate and use of numbers to support one side of the turf war.

As we enter the second year of the new public health era, EHPs MUST start to collate the vast amount health data held by LAs both at a local and regional level, without this evidence our voice will be lost. We must also look to our current functions to see where it fits to the local public health priorities and John Middleton offers a useful example which could be shaped in other services.  If there is one thing to learn from the above it is that the future remains uncertain but public health will continue to be a key function of the future LA and EHPs must learn to be part of this agenda and must learn to evidence the effectiveness of their interventions.

Brindle, D., (2014). John Middleton: ‘Public health is about making ordinary lives richer’  The Guardian, Wednesday 26 March 2014

Dunton J., (2010) Councils say “no” to public health ring-fence. Local Government Chronicle 5 Oct 2010.     www.lgcplus.com/briefings/joint-working/health/councils-say-no-to-public-health-ring-fence/5020148.article

Gamsu, M., (2014). BMA survey of public health workforce – transition and division? Local democracy and health available at http://localdemocracyandhealth.com/2014/03/31/bma-survey-of-public-health-workforce-transition-and-division/   dated 31.04.14.

Hetherington, P., (2012). Public Health will cost local government money. The guardian 26.06.2012

Iacobucci, G., (2014). Raiding the public health budget. BMJ Vol 348:g2274 pp 1-4

Jongsma, H., (2014) Findings from the public health survey. London, BMA Health Policy and Economic Research Unit

Royal Society of Public Health (2014). The views of public health teams working in local authorities year 1. London, RSPH

On the Cusp?

Environmental health has always had a role to play in housing conditions and with demographic change, the need to respond to ‘ageing in place’ is greater than ever. Environmental health is a key partner in helping ensure that housing, health and social care needs are effectively met and it is important that we think about our future roles now, the quality of services we would like to deliver (and potentially receive) and how health and care needs might be funded and otherwise resourced.

At a recent reception at the House of Lords, Care and Repair launched On the Cusp? Integration of housing, care & health for older people’. They are asking for their new brochures ‘On the Cusp’ which highlights the critical next steps in the current integration agenda, and ‘Ageing well at home’ which sets out the case for this being a useful principle upon which to base a range of policies concerning older people, to be widely circulated.

We hope you are able to include this work in informing your research and practice.

With best wishes, Jill

Housing and Health: Effective Collaborations

Already 2014 has seen some great events in London, with others planned, linking housing and health and identifying and helping to plug gaps in our evidence base.

A Joint Voluntary Sector Learning Event on Health and Housing in January drew together a range of housing and health speakers who raised several issues of interest to environmental health, including housing conditions, fuel poverty, housing and health needs of older people and children as well as health inequalities in the private rented sector. The Race Equality Foundation website provides access to evidence-based briefing papers with research and good practice examples. Discussions at this event highlighted other evidence bases, including the National Housing Federation partnership hub

Last week, Crisis and Shelter jointly launched their Lottery Funded study: A Roof Over My Head: The final report of the Sustain project (Sustain: A longitudinal study of housing outcomes and wellbeing in private rented accommodation). This is of fundamental interest to environmental health. Amongst other things it highlights the sector’s ability to accommodate the needs of homeless households and helps plug some gaps in what happens to families living in this sector by tracking experiences and wellbeing of 128 people who had been re-housed in the private sector following a period of homelessness. The numerous findings will not come as a great surprise to those working in environmental health and housing, including problems with conditions, costs, unsupportive landlords and length of tenancy and the ongoing trauma of feeling insecure without much hope that this might change, affecting confidence and anxiety. The complexity and combination of these factors has led to a constant struggle for tenants with a profound effect on their wellbeing, particularly for already vulnerable people with very few options or choices.

In another event last week led by the National Housing Federation, Public Health and Housing: A Pan-London Summit, sought to further integrate the new public health roles and responsibilities. It drew together a range of interested parties to think through issues including around commissioning housing and public health services through enhancing opportunities in Joint Strategic Needs Assessments and Health and Wellbeing Boards; developing safer neighbourhoods and mental wellbeing; and supporting tenants into employment.

Combined, these events have helped confirm a dynamic and committed workforce committed to addressing housing and health inequalities and looking for new ways to develop rigorous and evidenced ‘housing offers’ (more to follow on this another time….) that might attract further resource within the new public health structures.

Jill

Floods, evidence based medicine and the welcome return of MedAct

At the start of all my lectures I’m briefing our students to observe closely the media coverage of floods across the UK. None have yet been affected directly, unlike my own family members beside Chesil Beach and the River Avon, but heated discussions develop quickly and the unfolding events are a master-class in the politics of environmental health.

George Monbiot’s recent article ‘Drowning in Money’ (http://www.monbiot.com/2014/01/13/drowning-in-money/) engages with the catchment management evidence, raises important questions about spending on flood defence and goes far beyond the simplistic and loaded language of many of those we elect to represent us. But recent events remind me of an earlier article by Peter Preston from January 2005 entitled ‘Bureaucracy is fine for them, not us’ (http://www.theguardian.com/society/2005/jan/03/internationalaidanddevelopment.politics) where, in the wake of the Indian Ocean tsunami, Preston argues that effective bureaucracy can be “the greatest friend of those in need”. Monbiot raises important questions about this effectiveness at all levels, but the ongoing floods remind me of the utility of local administrators who, far from burdening businesses with red tape, contribute towards the very functioning of our economy and wider society each and every day come rain or shine.

Second, the 25th Jan. edition of the British Medical Journal (Volume 348:1-40 No 7942) includes a wonderful oral history article and video on the origins of evidence based medicine (that informed our own definition of evidence based environmental health) which is available for free via: http://www.bmj.com/content/348/bmj.g371

In her associated editorial, BMJ Editor Fiona Godlee summarises the evidence based debate before commenting that, with apologies to Churchill, it maybe the worst system for clinical decision making, except for all the others, and it’s “only as good as the evidence and the people making the decisions”.

Lastly, November 2013 saw the welcome rebirth of MedAct, a charity for health professionals that campaigns for a safer, fairer and better world. I first came across their work whilst living in South Africa when I attended a launch of the 2nd (highly recommended) Global Health Watch report (available for free via: http://www.ghwatch.org/) which was partly co-authored by MedAct members.

For more information visit http://www.medact.org/ , but the videos from their re-launch (environmental health) conference are excellent and include many leading agitators (e.g. Richard Horton, Allyson Pollock, Andy Haines) for a better global public health (see http://www.medact.org/relaunch-conference/ ). I hope that more environmental health professionals will be willing to get involved in their work, if so I hope to see you there!

With best wishes,

Rob

Some rather NICE news

Today we have exciting news.

Many EHRNet members contributed to the CIEH publication Effective Strategies and Interventions: environmental health and the private housing sector in 2013 and we are very pleased to let you know that this now appears on the NICE evidence base.

NICE disseminates ‘authoritative health and social care evidence and best practice’ – so having this CIEH publication there is great news and a real credit everyone involved. It demonstrates that our daily environmental health practice both addresses inequalities and yields real and recognised health impacts and outcomes. We need to ensure that we continue to disseminate this practice by publication to promote what we do and further influence the policy agenda.

Also, at the University of Greenwich we last night launched our Centre for Positive Ageing, led by Professor Pat Schofield. As part of this, Jill Stewart will be leading on the Environment, Housing, Health and Social Care Cluster and will be very happy to hear from anyone working in private sector housing in areas such as ageing in place, alleviating ‘bed blocking’, supporting home owners to stay in their homes, enhancing quality partnership services and so on. Many EHRNet members already have excellent strategies in place and we would also be very happy to discuss any possible joint working and funding opportunities your organisation may have so that we can explore enhanced housing related services and options for our ageing population.

With best wishes, Jill

Research briefing 2 & the missing whistleblowers

Dear colleagues,

A Happy New Year to you all.

At the end of November and to coincide with our workshop at the CIEH Education and Research Special Interest Group conference at Wolverhampton University we published our second free research briefing on what we consider important aspects of reading and writing for environmental health research and publication. This can be downloaded via the link below:

http://ukehrnet.wordpress.com/research-briefings-new/

Please also pass on this post to interested friends and colleagues.

To reduce Research briefing 2 to four pages we decided to remove the section from our eBook chapter on which it’s based on the importance of whistleblowers. Events last year including Edward Snowden’s revelations about government surveillance of our lives and ongoing cases in the UK National Health Service and Metropolitan Police (amongst others) remind of the importance of whistleblowers in illuminating what is actually happening on the ground and therefore in the comments section below this post we reproduce the paragraph from our eBook on this important and difficult area.

Lastly, we would welcome your thoughts on topics for future briefings and whether you found this briefing useful?

Many thanks and best wishes,

Caroline, Surindar, Rob, Jill and Alan