Environmental Health Practitioners are often called “jacks of all trades” which in terms of public health isn’t such a bad thing. Of course the popular adage then goes on to read “ and masters of none,” which also has a ring of truth about it. That last comment often leads to people being very protective about their occupation but in such a complex world as Public Health there can really only be a few masters.
A few weeks ago I attended the Health and Care Exhibition at Excel in London and was amazed by the variety of exhibitors ranging from CCG’s to tele health providers and those selling dietary supplements. Its easy to get overwhelmed in such company with some undoubted experts in their fields present. Interestingly though once I started talking about the wider determinants of health and drawing links to air quality, housing etc I felt I was the one imparting the knowledge.
Fast forward to this week and I attended an excellent Public Health Masterclass run by Professor Harry Rutter* on Obesity. If you want to know anything about that subject he most definitely is the man that you should call. During his presentation which I was glad to note unlike many had a completely down to earth feel he mentioned the story of the Hedgehog and the Fox. Turned into an essay by philosopher Isaiah Berlin its based on a work by the ancient Greek poet Archilochus. The origins maybe in the classics but actually the concept is very simple, the Hedgehog knows one big thing while the Fox knows many things. Berlin used it to divide writers and thinkers into two groups but its equally applicable to occupations. If we look at Public Health there are many Hedgehogs doing a very important job looking into individual areas in great depth, analysing data and producing evidence. The system couldn’t survive without them and its interesting to note most eminent scientists who end up winning Nobel prizes are definitely Hedgehogs. Whilst their work is vital it wouldn’t make a great deal of difference in the real world without a few Foxes around. The ability to take the evidence from specific areas and see the links is what they do best. Going back to the original adage they are certainly “jacks of all trades” but their input is a vital part of any system.
So where do EHP’s fit in all this? With increasing specialisation it could be argued that now we have officers solely doing food or housing work we’re actually turning out a whole family of Hedgehogs. That raises the question who is there left to see the obvious links with Public Health? DPH’s are certainly in the Fox camp but they can be isolated and torn in too many directions at times. Surely a profession that was raised to identify links between the environment and health should be perfectly placed. It is important to know your stuff when dealing with intricate bits of legislation but its equally important to be able to spot where Environmental Health can have an influence on better health outcomes. I fear over the past few years we have been doing much more of the former rather than the latter. There is of course one other problem as a colleague said to me “ we are definitely one of the occupations to make the links the only problem is it’s still Fox Hunting season in Local Government.”
* My thanks to Harry for the inspiration behind this blog post you can follow him on Twitter @harryrutter
In 1988 the World Meteorological Organisation and the United Nations Environment Programme created the Intergovernmental Panel on Climate Change. As births go it wasn’t an entirely straightforward one particularly as it brought scientists and policy makers together in one organisation. Previously the way of the world had generally been for the scientists to experiment and expound theories and the policy makers to largely cherry pick the ones that were most acceptable to their political masters. The IPCC being what some people termed a ‘border organisation’ was different. Before its original report in 1990 the panel was divided into three working groups:
Working Group I: assess the physical science of climate change and its causes and estimates of future climate change.
Working Group II: assess the impacts and vulnerabilities of climate change, including adaptation possibilities.
Working Group III: assess mitigation possibilities.
The first report wasn’t a particularly earth shattering affair concluding in fact that rises in global temperature were fairly consistent with climate models at the time. It was in 1995 that the cat started to be put amongst the pigeons as a ‘discernible human influence on global climate’ was reported. six years later the second report in 2001 confirmed that theory saying ‘warming over the past 50 years is likely to have been due to an increase in greenhouse gas concentrations.’ By the time 2007 rolled around phrases like ‘very high confidence’ were being used to describe mans influence on climate change. Which brings us to the recent trilogy the fifth round of reports that now doesn’t beat around the bush anymore and in simple terms implies ‘its happening, we’re to blame for most of it, so we’d better do something about it quick.’ Not the most scientific of explanations I grant you but something that after all the probabilities, confidence intervals and very possibles hard pressed members of the public will have no problems understanding.
Looking at the press though even that might be too simplistic a view. With such a major policy shift needed away from fossil fuels needed its logical to suggest an interim step because as much as we’d like to turning off the coal fired power stations all across the globe it is not going to happen overnight. What we need is a ‘halfway house’ or interim technology that is not the answer but will allow us to move in the right direction. Step forward fracking seen by some as the universal panacea for everything, and by others as not so much snake oil as snake gas. Here the messages start to get mixed; the IPCC says that fracking could be an important source of energy during the transition period but only if it replaces coal burning. The Daily Mail says “Fracking can help to slow global warming admit UN scientists.” The Daily Telegraph “Fracking can be part of solution to global warming.” Both true in their own way but only if qualified by the full facts. So the debate now shifts from whether global warming is happening or not to how do we address the issue which in one sense is at least a step in the right direction. It does however once again cloud the issue (no pun intended) as well in the publics mind at a time when we need concerted action not another 24 years of debate.
Its interesting to see how the IPCC progressed in its theories and how we should have got a firmer response by politicians in 2001when it started to become obvious where all this was heading. The fear now is whilst the debate has definitely moved towards mitigation it will take another quarter of a century to agree how best to achieve it. With the stakes much higher as our window of opportunity starts to close now is not the time to play politics.
The recent report by the IPCC has raised the stakes on climate change and its now down to governments to react.
Its also once again highlighted that what we are really talking about is the biggest public health issue we face in the decades to come. Food security, flooding, heat waves and water shortages all getting a mention with the authors making the point that every part of the globe will be affected. A few years ago there was a feeling on these relatively temperate isles that climate change was a problem for others to worry about, that theory though looks a little thin now. In 2009 I can remember attending an event at the Royal Society for Public Health which followed the launch of The Health Practitioners Guide to Climate Change. The day seminar was run by Jenny Griffiths one of the authors of the book and she looked slightly crestfallen that only 4 people had turned up. I was the only local authority representative along with three very nice ladies from the NHS. Despite the small attendance we all had a good day and learned a lot. The occasion though highlighted the thinking at the time that climate change had very little to do with health.
Five years on and a scary report from the IPCC later hopefully that mind set has changed a bit. The only problem now is with the continual erosion of those local authority services that can play a fundamental part in trying to control the situation its going to be a tough job literally trying to turn the tide. When I was first given the task of heading up sustainability at a small borough council we were facing a Use of Natural Resources inspection by the Audit Commission, whatever your views on the ‘big stick’ approach it certainly concentrated the members minds and suddenly sustainability became a serious issue. Along with a selection of KPI’s local authorities needed to report on even the most skeptical of members was forced to start thinking about mitigation and adaptation. Now the situation is completely different, Use of Natural Resources and KPI’s are a distant memory and local authorities have a collection of Climate Change Action Plans gathering dust on a shelf somewhere.
Its tough to see how even the apocalyptic forecasts in the new IPCC report will change things in that respect. The Stern review which came out as long ago as 2006 initially suggested an investment of 1% of GDP per annum was needed to avoid the worst affects of climate change that estimate was quickly upgraded to 2% in 2008. Whilst it got a very mixed reaction this weeks news would seem to suggest it was very much on the right lines. The Chancellor is no doubt happy that the bad news arrived after the latest budget speech.
So where do we go from here? The next stage of the IPCC report which is due out on 13th April may provide some hints. Instead of concentrating on whats likely to go wrong this will be an attempt to look at strategies for tackling carbon emissions. Its unlikely to present anything thats particularly new and will probably stoke up the same debates about renewables and nuclear power etc it will though be fascinating to see given the very clear messages of the Impacts report whether it will be looked on in a new light by those with their hands on the purse strings.
You can download a copy of Climate Change 2014: Impacts, Adaptation and Vulnerability here.
Following consultation with Local Authorities and members of the food industry the government has issued new guidelines on the display of Food Hygiene Ratings. From today it is recommended that ratings are prominently displayed on catering staff and food workers. Numbers from 0-5 are to be attached to workers clothing and should be worn at all times they are within view of members of the public. The move has the support of regulators and the industry alike but the innovative methods being adopted by some businesses has drawn criticism from the unions. Mr Ivor Tiesboy of the Fast Food and Associated Trades Union told us; “We welcome the new guidelines but feel that the tattooing of 5 star ratings on our members foreheads by some companies is a step too far.” Enforcement officers say that the new idea will add to confidence in the scheme. Mr Alf Rods of the Rodding Eye Agency said; “It’s certainly better than the first idea they had which was to put the rating on a bar code. In these days of efficiency savings it will save EHP’s time giving them an instant view on how a premises is performing.” It remains to be seen if the FSA will make the guidance compulsory, at the time of going to press they were unavailable for comment. The new Food Hygiene Rating Scheme Branding Guidelines are available on line.
I’m sure you’ve all seen the television adverts by now tempting us to rush out and dig into a brand new Cheeseburger Crust Pizza. Back in the early 1970’s when manufacturers decided to take those little blue bags of salt out of packets of crisps my Grandma exclaimed “whatever will they think of next.” The food industry has come a long way since then and I can only guess what she’d say now. Whatever your views on a culinary delight that offers my entire daily calorie intake and that I’d struggle to be tempted by if I was Robinson Crusoe one thing stands out for me the fact that its being produced by a company that have joined the governments Public Health Responsibility Deal. On its website the deal is described as aiming ‘to tap into the potential for businesses and other influential organisations to make a significant contribution to improving public health by helping us to create this environment.
Pizza Hut UK Ltd the UK’s largest pizza restaurant and delivery company made two pledges to the scheme in December 2011. One was concerning the ‘non use of artificial trans fat’ the other interestingly was ‘out of home calorie labeling.‘ Their action plan tells us that 322 dine in restaurants now provide calorie information on standardised food and drink items. After a slightly complicated search they are true to their word and you can find the fact that each mini beef burger contains 19.1g of fat and there are 10 of them on each pizza to start with. What I find really concerning is that nutritional information on the product is fairly freely available and yet Pizza Hut are obviously still meeting their sales targets. Its a point that throws into question the whole idea of the responsibility deal.Yes giving people choice is a good idea but will it really lead to an improvement in the nations health.
For many years as a nation unhealthy has been the default when it comes to fast food. Go to any event be it a concert or a football match and the most obvious choice is likely to be a burger or something with chips. London 2012 tried to redress the balance but at a price and in the shadow of one of the biggest fast food restaurants in the world just around the corner on the Olympic Park. Its hard to knock the ethos behind the responsibility deal but as Pizza Hut have demonstrated its simply not working. In one respect its trying to turn unhealthy food into healthy food which is unlikely to happen. A recent report in the British Medical Journal on ‘Takeaway Food and Health’ made the point that it should be about making healthy take away food “visible, tasty, and cheap as unhealthy food.” Easier said than done although the Greater London Authority have made a start with their ‘Takeaway Toolkit’ which is looking to work with the industry to provide healthy options. One other point made in the BMJ article was that restrictions on the numbers of take aways through planning laws may not be the best way forward. Fast food establishments can provide good social capital as meeting places and providers of entry level jobs, while food on the go has become a necessity of modern living for many. The direction then would seem to be clear ‘change the menu not the venue‘, the problem is though with the only current voluntary system failing to turn the market around and an administration loathe to introduce any compulsion to act we appear to have reached a road block. Our screens are still full of fried foods and cheeseburger pizzas and obesity rates continue to rise while the NHS continues to pick up the bill putting that system right should be all our responsibilities.
We are going through a time of unprecedented cuts to Public Services so how can we make sure that dwindling budgets still produce meaningful interventions? The economy is back on the rise or so the chancellor continues to tell us and unemployment is down although we could have a long debate about zero hours contracts, but in some areas it certainly doesn’t feel like it. Every morning seems to bring news of more local authority redundancies and cuts to services. A resuscitated economy may be one thing but when libraries, swimming pools and even public conveniences are closing because of a lack of funding there would seem little reason to celebrate. So how can local government prove its worth in real terms?
Finance in the NHS has been the subject of many millions of column inches but at least it can be recorded to a degree. The cost of a hospital admission, a doctors time, drugs etc are fairly well known so you have an idea with a degree of certainty how much each set of circumstances will cost. Take that formula back to local government and the situation is completely different. Sending an EHP out to inspect a category A food premises or to deal with a noise complaint can be reduced to unit cost but the savings to society are rarely contemplated. The Housing Health Cost Calculator is an example of the approach and has produced a lot of success in simply demonstrating the impact on NHS finances of removing a hazard. Even that though has its shortcomings, the savings showing on an NHS budget means local politicians are unlikely to be too impressed. There is a clear argument for budget sharing amongst all health and social care organisations to solve that type of issue but even with the return of Public Health to local government any moves in that direction would still be seen as too revolutionary by many.
It is perhaps true to say that EHP’s and other front line officers have been slow to come to terms with the need to justify their worth having hidden for many years behind a wall of statute. Now that the wrecking ball has smashed its way through many departments are hastily trying to play catch up. So how do we know where to spend hard pressed budgets, when is the price right? At this stage in most areas those are questions that simply can’t be answered but that doesn’t mean the approach is wrong. It means that front line services need to get smarter in proving what would happen if they weren’t around. The public naturally assume they can consume safe food, breath safe air and greet their loved ones back from work every night without fear of injury.
Few attempts have been made to put an accurate figure on what that costs and what would happen if those services were removed. It is likely to be the case that the Local Enterprise Partnership (LEP) have no idea but why should they unless someone tells them? A decade ago we had best value that turned into anything but mainly because bench marking is a blunt tool unless you are comparing like with like. Now though is surely the time for front line services to stand up and demonstrate their worth because if they don’t we won’t need to research the results of cuts on Public Health we’ll be able to witness them first hand.
Is our approach to Environmental Health still relevant to the 21st century?
Last week I attended a masterclass with Public Health England’s Professor Kevin Fenton, one of the things he said that really resonated with me was “ we need to stop doing the things that don’t work.” It’s the kind of statement that has you walking away thinking; ‘ he’s right you know’ but after a few more minutes you quickly change your mindset to ‘ but how do we do that?’ 30 years in Local Government taught me that judging success was not something we were very good at. If notices are complied with and food hygiene ratings go up we may think we’ve made a difference but in the big scheme of things have we? As the NHS continues to drown in demand and Public Health establishes itself in its new home focus is beginning to shift to the wide determinants of health and in doing so is looking towards services like Environmental Health for solutions whether we like it or not. Anyone who has read this blog will know I’m a complete convert when it comes to believing that 90% of health has nothing to do with the NHS. That school of thought though does rely on us being able to judge which interventions are worth pursuing and which however well intentioned make little difference.
Its an interesting debate when it comes to legislation which in some cases is based on thinking set over a century ago. The principle of ‘nuisance’ for example was originally included in the 1848 Public Health Act while going forward in history the Clean Air Act 1956 and the Health & Safety at Work etc Act 1974 are both over 40 years old. That of course doesn’t mean all old legislation is now irrelevant in these modern times but it does mean that to still be using ideas produced before the telephone was invented in some cases you have to be confident they still work. So how do we judge success? In todays austere times the call to concentrate on statutory obligations is often heard but what is rarely questioned is whether those statutory obligations produce the best return for the publics health. Going back to nuisance law the very wording of the legislation which places a duty on the local authority to investigate could be seen as being versed in a bygone era. In the nineteenth century most nuisances didn’t take much investigation as the piles of rotting material or fumes polluting the atmosphere were pretty obvious to detect. As society has become more sophisticated so have most of its problems. The smogs of the 1950’s were there for all to see air quality in 2013 is proving every bit as lethal but can’t be detected by our senses. Housing Action Areas presented big problems in the 1960’s now 25,000 people die every year because of cold temperatures most of whom are locked away in dwellings that wouldn’t have produced a second glance 50 years ago.
All that is happening in a world where success is often judged by public opinion and choice is the mantra. As many professionals find it difficult to make the links expecting the public to solve the issues is surely a step too far. To address sophisticated problems we need more subtle solutions the legislators of the 1800’s did an excellent job of starting to address their issues but I’m sure they would be amazed to learn in some cases we are still relying on their ideas to solve 21st century concerns. As we recede more into the statutory bubble the words of one pioneer of the past are every bit as relevant as they were almost 100 years ago “If you always do what you’ve always done you’ll always get what you’ve always got.”
First may I wish everyone a very Happy New Year and hope it brings you everything you wish for. I think 2014 is going to be a vital one for Public Health, last year Directors of Public Health were feeling their way in the new setup with plans being put into place as Local Government started to adapt to the return of one of its fundamental responsibilities. Some might unkindly say it was all talk and not a lot of do, an opinion which I certainly don’t subscribe to. There is though pressure in 2014 for all the good work of the past 8 months to start producing some results.
The economy is still the focus of politicians attention and that will only intensify as we get closer to the next election. The challenge facing Public Health is to get into the frame and prove that prevention and financial prudence can work hand in hand. To be honest things haven’t started too brightly with The Chancellor looking forward to “ a year of hard truths” with a further £25bn in spending cuts on the agenda. On initial consideration that seems in direct contrast to the smile on the face of the governor of the Bank of England a month ago when he told us we were back on the road to recovery. Has the patient suffered a relapse? If thats the case it could perhaps be a good thing for Public Health. Its been the rhetoric of successive governments to congratulate themselves on how much money they spend on the NHS while blaming the other lot for not splashing the cash half as much. That argument has little relevance to the quality of service as the Francis Report found out. If there is one hope for 2014 it’s that those in power wake up to the fact that 90% of health has nothing to do with the NHS. The third largest employer in the world behind the Red Army and the Indian Railway has done incredibly well to continue as it has since it was effectively bankrupt from 1950 when free dental care and spectacles caused Clement Atlee’s government to re visit their sums. But for every year that passes the pressure increases, and you can only put so much political hot air into a balloon before it pops.
There’s still a fundamental misunderstanding of the part Local Authorities can play in all this. The wider determinants of health have a massive influence on how many people turn up at the NHS’s door. Alcohol, tobacco, obesity, air quality and poor housing to name but a few are all vital ingredients in our picture of health. These though are the very areas where cuts to public service are having a negative effect. How many Environmental Health managers out there are being forced to par back their services to cover the statutory minimum because of pressure from government and local leaders? Surely the question should be, what can we do to make the biggest impact on Public Health? The knock on effect could be enormous for the local community and the NHS. Unfortunately in my experience that type of brave, informed leadership is sadly lacking in many areas where local politicians are loath to produce savings for anyone but themselves. If 2014 is to be a “year of hard truths” we can only hope that one of them is making further cuts to services that protect Public Health is a quick route to disaster for everyone.
Eat drink and be merry for……………..tomorrow you may be run over by a bus. Not exactly cheery words for the festive season but ones my Dad used every year before helping himself to a big glass of rum and cloves, one of his favourite tipples. The sentiment is one that many people will relate to at this time of year when healthy eating and cutting down on alcohol go out of the window all in the name of Christmas. You will have your views on whether thats a bad thing or not to use another well worn family saying I like my Granddads “a little bit of what you fancy does you good,” which as long as we stick to the ‘little’ seems pretty wise advice to me.
The average Christmas dinner contains three times the recommended salt intake and approximately 48g of fat but on its own is hardly going to make a great deal of difference. Eat one every day and that’s a different matter. Every year the press tend to dig out people who dress as elves and supposedly celebrate Christmas all year round with a tree, turkey and the works. It seems no coincidence to me though that you never see them the following year when the story is based around someone completely different! The food we don’t eat could literally feed an army and a very big one at that. In 2011 we threw away the equivalent of 2 million turkeys, 5 million Christmas puddings, and 74 million mince pies according to Love Food Hate Waste. While we’re talking rubbish you know Christmas has arrived because there’s no room in the bin. That’s because we dispense with approximately 83 kilometers of wrapping paper, 125,000 tonnes of plastic packaging and over 600 million non rechargeable batteries.
The festive season is also a time when you find people trying forms of alcohol they wouldn’t dream of touching during the year. Last night my brother in law asked for a sherry and believe me he isn’t usually the sherry type. I can remember my Granddad being given a bottle of Green Chartreuse, being a confirmed pints man he filled a half pint mug with it, took an enormous swig and spent the next 10 minutes trying to get his breath back. This year we’ll consume in the region of 600 million units of alcohol during December while New Years Day annually sees the highest number of emergency admissions to hospital for stays of less than 24 hours. Its a happy occasion for the most part but it can also be a very stressful one which may explain why the police record a third more incidents of domestic assault on Christmas Day compared to the daily average for the rest of the year.
Looking at that lot maybe the familiar strains of Wizzard singing ‘I Wish It Could be Christmas Everyday’ will take on a slightly new meaning in future.
Have a great Christmas and a Happy and Healthy New Year!
61 years ago it was very easy to judge that we had a big problem with air pollution, London had been engulfed in thick smog for 4 days until the choking population finally got a chance to breathe freely again on the 9th December 1952. Left behind was a trail of destruction that saw 4,000 premature deaths as a result of the daily dose of 1,000 tonnes of smoke particles, 2,000 tonnes of carbon dioxide, 140 tonnes of hydrochloric acid, 14 tonnes of fluorine compounds and 370 tonnes of sulphur dioxide which converted into 800 tonnes of sulphuric acid. As well as the human toll, the transport system had ground to a halt and even Sadlers Wells had to suspend a performance of Le Traviata when someone left the back door open and the stage disappeared in a thick smog. The reaction of the government of the time was for Prime Minister Harold Macmillan to reject calls for legislation by saying that there were; “an enormous number of broad economic considerations that have to be taken into account.”
Problems of poor air quality were first documented back in 1257 when Henry III’s queen Eleanor was forced to cut short a visit to Nottingham because of fumes from burning coal. Fast forward 756 years and the fuel may be different but the concerns are still as acute. Despite Mr Macmillan’s initial lack of action in the 1950’s pressure did finally result in the arrival of a major piece of Public Health legislation the Clean Air Act 1956. Within a decade the skies were clear again but just because you couldn’t see the problem anymore didn’t mean it had gone away. Like Queen Eleanor’s experience we just swapped one issue for another. At the start of the twentieth century there were only 8,000 cars in Britain by 1999 there were 21 million add to that the increasing motorway network, the reduction in rail travel brought about by the Beeching Report in 1963 and its not hard to see a crisis looming. Unlike 1952 or 1257 we can generally go about our lives without sensing the seriousness of the problem. Quite how large that problem is still creates much debate.
A recent report from scientists in Holland has suggested that levels of particulates well below current European standards are still harmful. If that is the case the 29,000 deaths already attributable to poor air quality may well be a massive underestimate.
So why the general apathy towards a subject that ranks alongside obesity and alcohol as one of the major Public Health issues of our time? Its a tough question to answer, mention air quality to members of the public and its high up the list but within Local Authorities it doesn’t seem to get the backing it deserves. Perhaps part of the reason for that is the technical nature of the subject and the fact that current policies have failed to join air quality with Public Health. For many years I asked colleagues about the health profile of their Air Quality Management Areas to be greeted with blank looks. It surely should be a fundamental part of the process to ensure those with the poorest health and protected as far as possible from areas with the poorest air quality. Another issue which harps back to Harold Macmillan’s feelings on the matter in 1953 is economics with Local Authorities seeing budgets disappear stopping continuos monitoring is seen as a quick win to boost the budget. Again a lack of joined up thinking means many Directors of Public Health are likely to be unaware of decisions made by their own authorities. As we look back over 61 years its difficult not to think that in real terms we’ve made very little progress as there is still most definitely something in the air.