Introduction
On 30 November, the Secretary of State for Health in England launched the
White Paper, Healthy Lives, Healthy People, which sets out the Government’s
long-term vision for the future of public health in England.
Since the early autumn, in anticipation of the publication of the White
Paper, the BMA has hosted a series of meetings attended by all major
English public health organisations - including the Faculty of Public
Health (FPH), the Royal Society for Public Health (RSPH), the UK Public
Health Association (UKPHA), the Association of Directors of Public Health
(ADPH), the Royal College of Nurses (RCN) and the Chartered Institute of
Environmental Health (CIEH). Many of these meetings have also been attended
by members of the Public Health Development Unit (PHDU) at the Department
of Health, and have been useful in enabling the exchange of ideas and
concerns in a receptive atmosphere.
As part of its work on the Public Health White Paper (PHWP), the BMA has
also met with other health organisations, including medical Royal Colleges,
as well as organisations with an interest in public health such as the
Local Government Association (LGA).
Additionally, the BMA organised a “Listening Event” on 12 January 2011,
which was attended by almost 200 public health specialists. The report1 of
the day was subsequently handed to Anne Milton, Parliamentary Under
Secretary for Public Health, and has also been sent with this response.
This report captures the breadth and depth of the public health community’s
voice in an unprecedented manner.
Therefore, whilst this response is that
of the BMA alone, we are certain that the issues that we raise are also
ones which are causing concern across all organisations with an interest in
public health.
1
Public
Health:
Our
Voice
http://www.bma.org.uk/images/publichealthbriefingourvoicemar2011_tcm41-204472.pdf
-
Summary
The BMA, together with the other organisations with an interest in public
health, is responding to the public health white paper, Healthy Lives,
Healthy People, whilst simultaneously responding to a Health and Social
Care Bill, which also covers public health in some depth. The landscape is
further complicated by the fact that primary care trusts (PCTs) and
strategic health authorities (SHAs) are already divesting themselves of
staff and responsibilities, before the remit of the organisations due to
take their place are fully known. There is a danger that any commentary on
Healthy Lives, Healthy People, could be like discussing the strength and
suitability of the bolt on the stable door whilst the horse has already
galloped off into the distance.
However, whilst this disordered transition period has added to the anxiety
of the public health community, it is not the main cause of their concerns.
There is a real worry across the public health community that the future
structure of the public health service envisioned by the government is
fatally flawed. Sending different elements of public into different
organisations, with different cultures and approaches, both to the NHS and
each other, could lead to the fragmentation of public health. These
concerns are very much in evidence in Public Health: Our Voice2, the report
of the BMA hosted event on 12 January on the NHS reforms, attended by 200
public health medical and non-medical specialists.
It is for this reason that in the BMA’s preferred model, all public health
specialist staff would be identified and transferred to a single public
health agency. This would be an NHS organisation which would second them to
Local Authorities as needed. As such, it would include all three domains of
public health practice – health protection, health improvement, and public
health support for commissioning. This model has much in common with one
recently published in the Lancet3.
The BMA believes that the creation of this model has several additional
benefits over the one suggested by the government. These include:





Co-ordinated training and career progression
More robust emergency planning and better emergency resilience
The continued ability of the Health Protection Agency (HPA) to
generate income
Public health retaining its independence from political interference,
either at a local or national level
Minimising disruption and stress to public health staff by ensuring
that they can maintain their NHS terms and conditions which will also
allow public health to remain an attractive career option for
trainees
The BMA has significant reservations about the power that the proposed
reforms will enable public health specialists to wield within in local
authorities. The major factor for success will be whether the Director of
Public Health and the specialist team are able to have control and lead
local public health. For this to occur, directors of public health need to
have full veto over the ring fenced public health budget They will need to
be prepared to give account of their actions to the local population and
elected representatives should they fail to deliver measured change in the
2
www.bma.org.uk/images/publichealthbriefingourvoicemar2011_tcm41-204472.pdf
Public health in England: an option for the way forward, Martin McKee et al, 28 February
2011.
3
1
local public's health. The profession is asking for authority, but it also
is prepared to accept responsibility.
Finally, it is vital that any reform of public health takes into account
all three of its domains; health protection, health improvement and health
care public health (support for commissioning). Too often the term “public
health” is conflated to mean only one or both of the first two domains, and
the commissioning aspect remains unaccounted for. More than ever, the NHS
needs the expertise of such a specialist workforce, who are highly trained
in commissioning services. Yet the Health and Social Care Bill, Liberating
the NHS and Healthy Lives, Healthy People, pay little, if any, attention to
their future.
2
General Comments
This, the main section of the BMA’s response to Healthy Lives, Healthy
People, is concerned with the proposed restructuring of the public health
workforce. This is because it is this restructuring which forms the basis
for the consultation questions for the White Paper as well as the related
consultation documents on the Outcomes Framework and the Funding and
Commissioning streams. For details on the BMA’s view of the scientific
evidence which makes up much of the White Paper, and provides the
government’s motivation for carrying out the structural reforms, please see
the Appendix.
The proposed reforms to the public health system in England, as outlined in
the government’s consultation Equality and Excellence: Liberating the NHS,
the subsequent Health and Social Care Bill and in this White Paper, have
caused great anxiety amongst public health community. This anxiety is
noticeable to anyone speaking to a public health doctor on the future of
their specialty and was particularly in evidence at a “Listening Event”
hosted by the BMA on the 12 January 2011. The event was attended by almost
200 public health specialists (including medics and non-medics) many of
whom expressed concern not only for their own roles, but for the very
future of public health.
The public health community’s concerns can be broken into two distinct
sections;

concerns over the future structure of public health; and

concerns around the transition period to this new structure.
The transition period
The process for the transition of public health to local authorities is
very uncertain for public health and the BMA believes that more details on
this process are needed from government.
There is a danger of losing
public health staff and expertise during this transition; especially as
many other Primary Care Trust staff are being made redundant.4
Indeed, despite Department of Health guidance making it clear that public
health posts should not be subject to management cuts the BMA has already
had to fight hard to counter attempts by PCTs in North West London,
4
Sir David Nicholson reported to the House of Commons Select Committee on 23 November that
PCTs
had
been
shedding
staff
in
an
“uncontrolled”
manner
www.gponline.com/News/article/1043440/PCT-redundancies-cost-NHS-40m/
3
Oxfordshire and Norfolk to include public health positions in the
restructuring of their management teams. This is likely to accelerate as
more PCTs enter into clustering arrangements.
Moreover, it is of particular concern that the Department of Health has
only guaranteed to fund regional public health observatories (PHOs) for the
first three months of the next financial year.
The BMA fears this could
create a skills gap before the proposed replacement, Public Health England,
is set up.
A letter written by DH Director General of Health Improvement
and Protection David Harper said‘further funding may become available as
business planning continues’.
He added that fixed-term contracts at PHOs
should not be renewed beyond their notice periods.
If there is a significant gap between PHOs winding down and Public Health
England being established, a cohort of specialty registrars may have less
opportunity to develop advanced skills in health intelligence compared with
their predecessors, with a detrimental effect not just for their careers,
but for the future health of the nation.
Public health structure
There is real concern across the public health community that the future
structure of the public health service envisioned by the government is
fatally flawed.
Sending different elements of public health into different
organisations, with different cultures and approaches, both to the NHS and
each other, could lead to the fragmentation of public health.
Therefore, in the BMA’s preferred model, all public health specialist staff
would be identified and transferred to a single public health agency, which
would be an NHS organisation and which would second them to local
authorities. As such, it would include all three domains of public health
practice – health protection, health improvement, and public health support
for commissioning. This model has much in common with one recently
published in the Lancet5
The BMA believes that the creation of this model has several additional
benefits. These include:
5
Public health in England: an option for the way forward? Martin McKee et al, The
Lancet, 28 February 2011.
4

Public health retaining its independence from political interference,
either at a local or national level, but positioned for political
engagement;

More robust emergency planning and better emergency resilience;

Maximising retention and motivation of public health staff by ensuring
that organisational and contractual barriers to flexible deployment
and career development are removed, through employment on a common
contractual basis (retaining current NHS terms and conditions), which
will also allow public health to remain an attractive career option
for trainees;

Co-ordinated training and career progression; and

The continued ability of the Health Protection Agency (HPA) to
generate income. Currently only half of the HPA’s annual budget of
£360m is from the Department of Health. The rest is self-generated
through research grants and commercial activity. However, becoming
part of the civil service will bar the HPA from these income strands.
Since this work, and those doing the work, cannot be separated from
other HPA functions, moving the HPA into the civil service will likely
lead to significant loss of jobs.
The above concerns were reflected in two motions passed at the BMA’s
Special Representative Meeting (SRM) on 15 March 2011.6:
That this meeting is alarmed that the government’s proposals if
implemented will lead to the fragmentation of the specialist public
health workforce in England and calls for the creation of a single
public health agency in England which shall be an NHS body including
all three domains of public health practice – health protection,
health improvement, and public health support for commissioning.
and
That this Meeting believes that, in recognition of the role of health
care services in improving health and addressing health inequalities,
public health doctors (including Directors of Public Health) should
retain the right to remain employed by the NHS under the proposed new
public health arrangements
6
On the 15 March 2011 the BMA held a Special Representative Meeting (SRM) to
debate the NHS reforms which was attended by several hundred doctors from across
the country. For more information on this meeting, including a list of carried
motions, see:
www.bma.org.uk/healthcare_policy/nhs_white_paper/specialrepresentativemeeting.jsp
5
Public health and local government
The BMA has significant reservations about the power that the proposed
reforms will enable public health specialists to wield within in local
authorities.
It is our view that if the vision of the current government is to be
realised, there needs to be more than inspirational ideas from Whitehall or
guidance from Public Health England.
Successfully shifting responsibility
for public health delivery to local authorities requires a carefully
defined and agreed framework between Whitehall and Town Hall.
The major
factor for success will rest upon whether the Director of Public Health and
the specialist team are able to have control and lead local public health.
As such, we welcome Annex A: A vision of the role of the Director of Public
Health, and in particular the section on the DPH as principal advisor.
However, in order for this vision to be implemented, the DPH needs to be
allocated several specific powers and responsibilities. These should
includ; the ability to report directly to Chief Executive Officers of local
councils and elected officials; the right to full veto over the ring fenced
public health budget and be fully accountable to the local population and
elected representatives should they fail to deliver measured change in the
local public's health.
The profession is asking for authority, but it also
is prepared to accept responsibility.
This is reflected in the below motion, which was passed at the BMA’s SRM on
15 March 2011:
That this Meeting calls upon the BMA to negotiate with government to
ensure that those filling the role of Director of Public Health
within a local authority are:i) professionally independent and free to act as an advocate for the
health of their population;
ii) properly appointed according to the appointments advisory
committee process and registered specialists in public health or
public health medicine;
iii) given appropriate authority and control over sufficient
resources to deliver public health functions effectively;
iv) responsible and accountable for the ring-fenced public health
budget;
6
v) afforded the status of ‘Executive or Corporate Director’ and able
properly to influence all funding streams with public health impacts.
Commissioning
It is important to note that the scope of public health extends to
activities delivered by health care services, including those in general
practice and in hospital.
Public health has always played a critical role
in leading transformational change of health services.
In recent years,
the financial agenda has become dominant within NHS administration,
accompanied by a dilution and diminution of the voice of the healthcare
public health workforce.
to be reversed.
The BMA believes that this marginalisation needs
Public health specialists are trained to prioritise
evidence for healthcare, to rate its effectiveness and to commission
healthcare services based on the health needs of local populations.
If the
government desires a realisation of its vision to improve the NHS through
clinical leadership, the missing link is to be found when public health
specialists are working together with GPs and healthcare professionals from
all parts of the care pathway to ensure the delivery of appropriate,
affordable healthcare of high quality. The role of public health in
commissioning is dealt with in more detail in our response to Consultation
Question a) below.
Evidence
Finally, in the foreword to Healthy Lives, Healthy People, the Secretary of
State for Health, Andrew Lansley lists the public health problems facing
England, including; the highest levels of obesity in Europe; among the
worst rates of sexually transmitted diseases; problems from drug and
alcohol abuse; smoking and poor mental health. These problems, it is
argued, require not only that the government do something, but that it does
something “bold” and “new”. This analysis of an unfit for purpose public
health system reflects the Secretary of State’s vision of a failing NHS.
Yet this view has been rebutted in several academic articles, including two
in the British Medical Journal by the King’s Fund’s Chief Economist, John
Appleby7. At its SRM the BMA passed the following motion:
7
Does poor health justify NHS reform? BMJ 2011; 2011; 342:d566 & How satisfied are
we with the NHS? BMJ 2011; 342:d1836, John Appleby
7
That this Meeting deplores the government’s use of misleading and
inaccurate information to denigrate the NHS, and to justify the
Health and Social Care Bill reforms, and believes that:i) the Health Bill is likely to worsen health outcomes as a result of
fragmentation and competition;
ii) the NHS needs to respond to the challenges presented by altered
patient demographics, and by development of medical technology and
medical care provision;
iii) the NHS needs national planned and coordinated strategies and
frameworks to improve health outcomes.
Whilst there is evidence that the NHS is working well8, there is less
evidence on the performance of public health medicine. However, the BMA
does not believe that this means public health as a specialty is failing,
but that it instead reflects the difficulty in gathering evidence on the
influence of public health interventions. There are several reasons for
this. First of all, it is too simplistic to say that public health as a
medical specialty is failing because, for example, health inequalities are
increasing. Health inequalities are the result of myriad influences outwith
the health sphere, not least socio-economic decisions made by government.
What the evidence does illustrate is that the health of the poorest in
society continues to improve and has done so over the last decade but the
health of the wealthiest in society has also increased over the same
period.
9
We would also contend that the numerous reorganisations of public health
have proved to be disruptive. Each one has resulted in a loss of specialist
expertise from the workforce, impacted negatively on corporate memory and
failed to afford public health delivery equivalent importance to that given
to other parts of the healthcare service.
Public Health delivery will
benefit from the setting up of a robust, sustainable public health service
that is independent of political direction and which is placed to act in
response to the population needs that it identifies through appropriate
surveillance of the state of the population’s health. We fervently hope
that the model which emerges from the current restructuring will be one
which endures for many years.
This will allow public health as a specialty
time to carry out the necessary and long-term work of improving the health
of the nation.
8
Does poor health justify NHS reform? ibid
Fair Society, Healthy Lives: The Marmot Review, Figure 2.1 Life expectancy at birth by
social class, a) males and b) females, England and Wales, 1972–2005
9
8
9
Consultation Questions:
The BMA welcomes the opportunity to respond in detail to the five
consultation questions raised in Healthy Lives, Healthy People.
(a) Role of GPs and GP practices in public health: Are there additional
ways in which we can ensure that GPs and GP practices will continue to play
a key role in areas for which Public Health England will take
responsibility?
It is important to recognise the role that GPs already play in delivering
public health improvements, as well as noting the external factors that can
constrain this work. These include pressures on GPs (such as time
limitations and unreasonable levels of documentation); the difficulty in
finding appropriate help and support and the fact that initiatives are
often not sustained.
If the public health role of GPs and GP practice is to be developed, the
work needs to be focused, evidence based and well-resourced. The
relationship between GPs and public health, and in particular those
practising health care public health (HCPH), is crucial in the development
of these services.
There is an urgent need to maintain the numbers of HCPH
specialists and this can only be done after a careful consideration of
where they are to be based.
This is one of the reasons that so many people are concerned about the
almost total absence of reference to public health support for
commissioning (or health care public health) in either Liberating the NHS
or Healthy Lives, Healthy People. Due to this lack of reference, and
because it is the least understood of the three domains of public health,
this section will first give an explanation of what health care public
health is. It will then go on to discuss its role in GP commissioning, how
active GPs can be effective commissioners and, finally, where HCPH
specialists should be based.
What is Health Care Public Health?
Health care public health describes a set of public health skills acquired
as part of specialist public health training and practised by members of
10
the public health specialty who are involved with the commissioning of
health care services.
Core competencies for HCPH include:

Assessing health needs of populations, and how they can best be met
using evidence-based interventions;

Supporting commissioners in developing evidence based care pathways,
service specifications and quality indicators;

Providing a legitimate context for setting priorities using
‘comparative effectiveness’ approaches and public engagement.
These competencies are needed in order to sustain health services within a
cash-limited system.
A further role which can fall to HCPH is that of engagement with the public
over service development and in particular over the prioritisation of
services.
HCPH is ideally placed to undertake this function because it
relates to populations and not individuals and therefore is free of
conflicts of interest in relation to individual patients or treatments.
This function is not just about conveying to patients in lay terms the
relative benefits of treatments or groups of treatments for particular
conditions.
Crucially, this function must also deal with the issues of the
relative importance of treatment for different conditions or groups of
patients within an overall cash-limited system.
This role of HCPH as
honest broker will be key to protecting the ability of general
practitioners and hospital specialists to continue to act, and to be seen
to act, in the best interests of their individual patients.
Government has offered the medical profession the opportunity to take
greater control of health services, inviting general medical practitioners
to lead the commissioning process. For this approach to succeed and so
secure the future of the NHS, the BMA believes that it is essential that
the key role of the specialist in health care public health is clearly
understood by all NHS staff and by government, and proper provision made
for its place in support of GP commissioning.
Health care public health and GP commissioning
Commissioning aims to ensure that available resources secure the right
technologies, in the right places, to provide as much health improvement
and health care as possible. This occurs within an ever changing
11
environment as health needs change, new technologies and/or evidence of
effectiveness become available and the amount of funding fluctuates.
In general medical practice, the doctor has responsibility for mobilising
appropriate local health resources in support of the needs of their
patients.
Consequently, GPs are in a strong position to understand the
needs of their own patients.
Yet, this view, derived from their own day-
to-day practice, is only one aspect of a strategic view.
Within the
general practice community, even within a locality or community, there will
be many GPs, each with a unique view.
The role of the health care public health workforce is to assist general
practice commissioners in synthesising their individual view of health
needs into a position that can be used to drive commissioning on behalf of
their consortia’s registered population.
Successful criteria for commissioning include:
1.
The ability to command support when making choices about the
allocation of resources;
2.
Balancing resource allocation decisions across the whole of the
healthcare portfolio for both existing and new services;
3.
Minimise unnecessary health care interventions and use of poor
value interventions;
4.
Setting out specifications and standards for services that will
achieve the clinical, quality and productivity outcomes sought and
securing these through the contracting process;
5.
Monitoring services to ensure delivery of these outcomes;
6.
Developing and improving the care pathway for patients to better
achieve desired outcomes.
Underpinning these are the transactional aspects of commissioning. Having
decided ‘what we need’ and ‘how much we need’ and ‘with what resource’ and
‘to what standard’ there are elements of commissioning concerned with the
contracting and procurement that govern ‘from whom’, ‘at what cost’, and
‘how to measure the results.’
The contracting and procurement aspects of
the commissioning cycle need to be undertaken in consultation with
commissioners and public health specialists, but not directly by those
groups.
The delivery of successful commissioning is a team undertaking.
This team
includes information scientists, experts in systems change, public
12
engagement and communications specialists and project managers as well as
HCPH. This paper focuses on the contribution of HCPH that can:
1.
Summarise the evidence setting out the relative value of different
interventions;
2.
Set out the contribution that interventions make to defined
outcomes and the relative return of investment across portfolio of
commissioned services;
3.
Identify areas for disinvestments;
4.
Design monitoring and evaluation frameworks, collect and interpret
results;
5.
Support the development of care pathways to improve patient
outcomes.
Effective GP commissioning by GPs
General Practitioner commissioners acting on behalf of their colleagues and
peers and the patients registered to a consortia will also remain providers
of primary care.
It is inevitable that, from time to time, dilemmas will
arise between the GP as provider of care and the GP as commissioner of
care.
A mechanism is required to deal with these dilemmas.
We propose
that the incorporation within commissioning process of public health
specialists operating in the field of health care public health provides
the route to resolve these issues.
HCPH specialists operate as ‘population doctors’ whose work is founded on
explicit utilitarian principles: the greatest good for the greatest number.
HCPH specialists operate by using information to examine the health needs
of a population and develop diagnostic hypotheses, undertaking relevant
investigations which seek to test these hypotheses and then formulating
appropriate responses based on expert knowledge drawn from a range of
sources, including that of local experts in primary and secondary care.
They offer independence and objectivity on individual cases, because they
work at population level.
HCPH specialist workforce is an essential ingredient in securing excellence
in GP commissioning.
This workforce has undergone specialist training and
plays a critical role in the specifying and sourcing of data and the
analysis and interpretation of that data to create intelligence to inform
commissioning.
Data without interpretation remains statistics.
Health
care commissioning based exclusively on data will always be passive.
Health care commissioning based on expertly crafted intelligence will lead
13
to active commissioning, able to define, to pursue and to achieve sought
after objectives.
Alongside the public health specialist workforce there is a need to imbue
public health skills in two other key groups.
For general practitioner
commissioners there is a need to provide a set of public health skills that
enables this group to understand the benefits and limitations of a
population approach.
Developing this skill set would enable GP
commissioners to undertake some public health tasks themselves.
More
importantly, it would also furnish such commissioners with an ability to
understand when it was appropriate to make referrals of issues to public
health specialists, and to frame issues in public health terms.
It would
also enable GP commissioners to assess critically the quality of product
provided by public health specialists and facilitate shared ownership of
emerging decisions informed by public health input.
For secondary and tertiary specialists, usually employed as consultants in
hospital specialties, there is scope for the re-emergence of the clinical
epidemiologist.
This group comprises specialist clinicians who in addition
to their primary specialty, are also trained in specialist aspects of
public health medicine.
Equipping a group with such skills enables them to
contribute a specialist clinical perspective informed by a population
approach and is essential in developing whole systems of care that span all
healthcare sectors.
Where should health care public health specialists be based?
The government plans to relocate the vast majority of the public health
workforce in England to homes within Public Health England (PHE) and local
authorities.
It is clear that public health is about improving health
outcomes and that much of this work has to focus on tackling the wider
determinants of health. The government has also mapped out a process to
migrate the Health Protection Agency into the proposed national Public
Health Service.
Although this strategy has much to commend it, it
endangers the HCPH function that has developed within the local NHS
environment since 1974.
There is a compelling argument that health care public health needs to be
retained within the NHS, as part of the commissioning function of the
reformed NHS. We believe that GP consortia need to have ready access to
HCPH, along with other skilled support staff.
At present there are about
14
250 public health physicians across England.
This dedicated specialist
workforce is augmented by a larger number of public health specialists
currently working in commissioning organisations and who incorporate
elements of health care public health within jobs that also include health
protection and health improvement roles.
There is a need to employ this
workforce in a manner that preserves its utility and provides cohesion and
continuity.
We do not believe that local authorities will see the support
of health care commissioning by GP consortia as part of local authority
business, and accordingly we would counsel that the health care public
health workforce requires an alternative home that secures its expertise
within the NHS family.
Employment of the HCPH specialist workforce could be secured within the NHS
in a number of ways.
These include:
 Transfer of those currently working in specialised commissioning into
the National Commissioning Board;
 Transfer of health care public health specialists into Public Health
England and contracting services back to commissioning consortia;
 Transfer of HCPH physicians into the larger GP consortia;
 Transfer of HCPH physicians into host GP consortia, to work across a
sub-national area;
 Transfer of HCPH into a host local authority to contract services
back to commissioning consortia;
 Transfer of HCPH physicians into universities on honorary NHS
contracts, with rolling contracts for provision of GP commissioning
support.
HCPH will best be organised to deliver a critical mass of expertise that
provides resilience in the face of organisational evolution; that offers an
ability to cope with a wide range of demands and to avoid duplication of
work in relation to appraising evidence for clinical services and models of
care; and yet is situated sufficiently locally to develop the working
relationships needed to be a trusted source of both informally and formally
commissioned advice.
In practice, this will mean locating HCPH at a level
larger than local authority (to obtain critical mass) but more local than
current regional structures to relate effectively to consortia and local
authorities and to enable responsiveness to local demands.
This could be
incorporated into the proposed national Public Health Service, thus
preserving all three domains of public health within that service.
15
Our clear preference would be for options which maximise the co-location of
specialists in all three domains of public health.
This is important to
ensure the critical mass of specialist workforce and to maximise the cooperation across all three domains of public health in optimising
population health.
It is currently envisaged that specialist public health trainees will be
placed within the national public health service and seconded to other
public health settings in order to obtain the experience and develop the
competencies required for specialist practice.
Of necessity, this will
require trainees to work across Local Authority, NHS and university
environments.
The career option for doctors wishing to work to improve
health services would remain, with the continuation of the role of the
public health physician.
16
Public Health Evidence:
General Comments
The BMA welcomes the opportunity to further strengthen the intelligence
functions of public health. We are reassured by statements from the
Department of Health Equality Delivery System team that health data will
include monitoring all six strands of diversity10, as a core requirement of
all NHS Commissioned Services. This is fundamental to delivering the NHS
Charter commitment to equity and equality and without this level of
evidence there is a risk that the NHS will remain opaque about
discrimination in delivery of services.
In order for this evidence to be of any use there will need to be adequate
capacity to analyse the information and present it in an accessible and
appropriate manner.
This reinforces the need for a national hub for
minority public health - similar to units in the US and New Zealand11. We
would also suggest that every NHS commissioned service is asked to publish
their annual performance for the six legal strands, for key indicators
including mortality, readmissions and length of stay.
Wider partners can contribute to this by implementing similar frameworks
for recording data and through joint strategic needs assessments.
(b) Public health evidence: What are the best opportunities to develop and
enhance the availability, accessibility and utility of public health
information and intelligence?
Of primary importance is the need for Public Health England (PHE), in which
ever form it takes, and the National Institute of Health Research (NIHR) to
develop clear quality standards to which providers of public health
evidence and information would have to adhere. These standards must relate
to both the completeness of the evidence and the validity of the
information.
Many of the examples of good practice that have been shared
(through, for example, Strategic Health Authorities or Darzi Programme
boards) have been insufficiently detailed on a number of areas.
In
10
The six strands of diversity are age, disability, gender, race, religion or belief and
sexual orientation.
11 For more information on the US Model can be viewed please visit:
http://minorityhealth.hhs.gov/ Further details on the New Zealand Model can be seen here:
www.moh.govt.nz/moh.nsf/pagesma/321
17
particular, the exact population for whom the flagship intervention or
programme was intended; the previous level of service; and, on which
outcomes were measured and over what time.
Secondly, there also needs to be specific consideration given to the fact
that the intended audience of much of this evidence will be local authority
elected members , who do not have detailed knowledge of, or training in,
public health. It should be clear from the title of these documents that
they are tailored specifically for the consideration of the member with
responsibility for health. In order to achieve this, appropriate language
and lay explanation of health terms must be given (with which public health
doctors can help).
Any briefing to elected members must also be must be backed up by a
scientific briefing document, with references, that public health doctors
can use to facilitate further local discussion.
There are a number of concerns that placing public health within the local
authority will interfere with the ability of the Director of Public Health
and their team to have access to NHS derived information on the health of
populations and the local and national patterns of use of health care and
outcomes from health care use.
These are not trivial matters, since public
health practice is based on the scientific discipline of epidemiology, and
without access to relevant and timely data public health teams will not be
able to function effectively.
Public health specialists within both Primary Care Trusts and Universities
should work in and with Public Health England to help the setting of
quality standards for evidence and the quality standards for scientific
briefing documents.
(c) Public health evidence: How can Public Health England address current
gaps such as using the insights of behavioural science, tackling wider
determinants of health, achieving cost effectiveness, and tackling
inequalities?
First of all, there must be a transparent process through which research
funding is prioritised, which takes into account criteria such as
prevalence of the risk factor and severity of the resulting ill health. For
the sake of credibility and rigour, the BMA believes that a University that
18
has experience in the science of decision making should run the process.
The London School of Economics (LSE) and Universities of Cranfield, Warwick
and East Anglia all have experience in recognised methods. We do not
believe that accountancy firms, management consultancies or other private
sector organisations are suitable candidates for carrying out this work.
Secondly, it is likely that PHE will be the organisation best placed to
have a global view of the current state of research in each of the risk
factors, diseases and populations. Special attention should be paid to the
study type. For example, if there have been six reported uncontrolled
pilots of a particular public health intervention, then clearly it would
make less sense to commission a seventh uncontrolled pilot, but instead
commission a controlled pilot.
The BMA believes that only this transparent and organised approach will
result in the public health community having the ability to answer the
question, ‘What is the next most pressing research priority in our field?’
19
(d) What can wider partners nationally and locally contribute to improving
the use of evidence in public health?
The BMA believes that there is a role for wider partners to make a
contribution to improving the use of evidence in public health.
This
includes having a transparent input into both prioritising research funding
and into developing the research question itself.
Whilst ‘Do breastfeeding classes increase the chances of mothers’
breastfeeding babies for six months?’ is a valid research question, a more
pertinent research question also will take into account the current
circumstances. In this instance, the question needs to take into account
the existence of SureStart centres and responsibility of Local Authority to
their resident population.
A more focused research question would be ‘Do breastfeeding classes in
Surestart centres improve the proportion of mothers within a Local
Authority who breastfeed for six months?’
Moreover, much of current research only looks at improvements in outcomes
for those attending available services. To be truly useful to a local
authority, research must be undertaken at population level, with outcomes
measured from samples or records taken from the whole population including
those who do not attend services.
Finally, much as in the answer to Consultation Question (b), it is vital
that results should be tailored and disseminated as audience-specific
briefings - both for elected members and the public health doctors - with
the latter containing the technical detail including references and
supporting data.
20
e. Regulation of public health professionals: We would welcome views on Dr
Gabriel Scally’s report. If we were to pursue voluntary registration, which
organisation would be best suited to provide a system of voluntary
regulation for public health specialists?
We fully support the recommendations in Dr Scally’s report that all public
health specialists are subject to a robust system of statutory professional
regulation and that the Health Professions Council (HPC) should regulate
public health specialists as an additional profession. We also support the
recommendation that there is no substantial change in the roles of the
General Medical Council, the General Dental Council and the Nursing and
Midwifery Council in respect of public health.
The BMA calls for the
statutory regulation of all public health specialists in line with doctors’
statutory regulation.
We categorically reject the government’s expressed
wish to pursue the voluntarily registration of non-medical public health
specialists.
There are several reasons for this. The most important is the safety of the
public at large. Not to expect non-medical public health specialists to be
statutorily regulated, whilst at the same time demanding that professions
such as chiropodists and arts therapists are, fails to appreciate the
significant role that public health specialists can have in shaping the
health of an entire population. Public health professionals make
substantial and fundamental decisions about the health and well-being of
the population. Like drug therapies, decisions and interventions made by
public health specialists can have intended beneficial effects.
However,
mistakes and misconduct by public health professionals can have serious
adverse and long lasting impacts, potentially most importantly in emergency
events and threats such as pandemic flu. Whilst doctors in public health
medicine are held up to medical professional standards through the GMC, and
some health professions
such as nurses have similar regulatory bodies, it
is important that all public health professionals are held up to the
highest professional standards because of the gravity and importance of
public health advice.
Another reason for the statutory regulation of all public health
specialists is public opinion.
In his letter to the Chief Medical Officer,
Dame Sally Davies, which opens his report, Dr Scally states that “Central
to the role of professionals in this modern age is the necessity of
establishing and maintaining the respect of the public.” This is
21
particularly true in an occupation that spends much of its time proffering
lifestyle advice.
The role and title of “doctor” is already well
understood and respected, with the general public maintaining a trust of
doctors not seen in other professions,
12.
It is unlikely that the public
would be as willing to listen to the advice, or respect the decisions, of
someone who they knew not be professionally regulated.
For this reason, amongst others, failing to regulate non-medical public
health specialists also undermines the work undertaken across public health
to establish parity between medical (doctors) and non-medical (other
professional backgrounds) specialists. Several years ago the Faculty of
Public Health established parity in training and appointments between
medical and non-medical specialists for public health and expanded the job
description of consultants to encompass non-medical consultants. The BMA
believes that public health is strengthened by the diversity and breadth of
these backgrounds and that this model establishes a rounded framework that
is more robust for this inclusive approach. However, the equality of
training and appointment is undermined by the inequality around regulation.
Such an approach, since it holds doctors to a higher standard than their
non-medical colleagues, is unfair both to doctors (since it demands of them
something not asked of their non-medical colleagues) and to non-doctors
(since it suggests to them that their experience and qualifications still
do not make them equivalent to their medical colleagues).
We therefore believe that statutory regulation is vital to protect the
public; to ensure their continued confidence in the decisions the specialty
makes on their behalf; and, to maintain and advance the unity of public
health as a specialty.
March 2011
12
92% of British adults aged 15+ say they would generally trust their doctor to
tell the truth - Annual Survey of Public Trust in Professions, MORI on behalf of
the Royal College of Physicians (RCP). (2009)
22
Appendix
The table below is a summary of the BMA’s Board of Science’s work and
subsequent recommendations on the topics covered in Healthy Lives, Healthy
People.
Health Lives
Health People
Inequalities
At the 2010 Annual Representative Meeting (ARM)13, the BMA
in health
endorsed the Marmot Review and strongly urged government to:
(i) take forward the recommendation that expenditure on
preventative services increase;
(ii) increase the proportion of overall expenditure allocated
to the early years to give every child the best start in
life;
(iii) set a 'minimum income for healthy living';
(iv) adopt fiscal policies to narrow the income gap between
our poorest and richest citizens.
Following the publication of Fair Society, Healthy Lives: A
Strategic Review of Health Inequalities in England (the
Marmot Review) in February 2010, the BMA has undertaken a
programme of work to consider the role of doctors in
addressing the social determinants of health inequalities. In
October 2010, the BMA hosted a breakfast debate on health
inequalities which was chaired by Dr Hamish Meldrum (Chairman
of BMA Council) and included Rt Hon Andrew Lansley CBE MP
(Secretary of State for Health), Professor Sir Michael Marmot
(BMA President) and Professor Sir Ian Gilmore (Immediate Past
President, Royal College of Physicians) as guest speakers.
The debate provided an opportunity to hear the government's
response to issues over health inequalities and the NHS white
paper. On 4 November 2010, BMA President Sir Michael Marmot
hosted a roundtable meeting and dinner with representatives
from the medical Royal Colleges and other key stakeholders to
discuss ideas on how each organisation will encourage and
support the development of policies and activities to address
13
23
the social determinants of health. The BMA hosted a
conference on the 10 February 2011 to celebrate the one year
anniversary of the publication of Fair Society, Healthy
Lives. This explored ways in which the social determinants of
health can be addressed through local action, in particular
how the medical profession can support this.
Section 3.5 – 3.12
Starting well
Breastfeeding The 2009 BMA Board of Science report Early life nutrition and
life long health
highlights the importance of breastfeeding
and raises concerns about the need to increase breastfeeding
rates in the UK – including addressing the inequalities in
breastfeeding between socio-economic groupings.
The report concluded that breast milk is the ideal food for
babies in their first few months. Mothers need support in
order to breastfeed successfully. There is consistent
evidence of better childhood cognitive development, and a
lower risk of several disease outcomes including obesity and
diabetes, in children and adults who were breastfed rather
than formula-fed.
Section 3.13 – 3.28
Developing well
Personal,
The BMA has long supported the strengthening of sex and
social and
relationships education (SRE) in schools, and the Board of
health
Science has published a number of reports in this area
education
including Adolescent health
(2003), Sexually transmitted
infections (2002) (the Board of Science produced an update to
this report in 2008 )
and School sex education: good
practice and policy (1997).
The implementation of well-designed SRE programmes in schools
is an important measure in reducing teenage pregnancy rates,
delaying the onset of sexual activity, and increasing access
24
to contraception and sexual health services. The need for an
effective school-based programme was reaffirmed at the BMA’s
2008 ARM where members called for SRE to be delivered to a
nationally standardised curriculum by specialist SRE
Teenage
teachers, beginning at primary school entry.
pregnancy
The BMA supports measures to reduce teenage pregnancy rates
in the UK. As highlighted in the 2003 BMA Board of Science
report Adolescent health, teenage pregnancy can adversely
impact on the health, educational opportunities and social
development of the parent and the child. Rates of teenage
pregnancy in the UK remain the highest in western Europe. The
BMA believes that greater emphasis is therefore needed on the
Change4Life
prevention of teenage pregnancy in the UK. Any teenage
pregnancy strategy should also be supported by broader
strategies aimed at reducing socioeconomic deprivation and
Improving
inequalities.
diet and
nutrition,
and promoting The BMA signed up as a partner to the Change4Life campaign in
physical
November 2008.
activity
As highlighted in the 2005 BMA Board of Science report
Preventing childhood obesity, there has been an alarming rise
in the levels of obesity among children in the UK and more
recent predictions anticipate this trend to continue. The BMA
believes there is an urgent need to take action to create an
environment that supports and sustains healthy eating and
physical activity. This requires a comprehensive, long-term
strategy that encourages healthy choices through action in
the following areas.
The BMA believes the UK Governments should:

ensure that the food and drink industry implement a
standardised, consistent approach to food labelling based
upon the traffic-light front-of-pack labelling. This should
also include Guideline Daily Amount (GDA) information
25

legislate for a ban on the advertising of unhealthy
foodstuffs, including inappropriate sponsorship programmes,
targeted at school children

make more extensive use of the media, including
children’s programming, to promote healthy lifestyle messages
that make such lifestyles both fun and aspirational

introduce a legal obligation to reduce salt, sugar and
fat in pre-prepared meals

ensure that adequate funding for healthy school meals is
ring-fenced from the education budgets of schools and
education authorities

subsidise the cost of fruit and vegetables to encourage
healthy eating

ensure funding to establish and sustain training
programmes for those who are involved in the care of children
with obesity

promote the importance of fetal and early life nutrition
and its relationship to lifelong health
Accidental
death and
injury

provide education and support that promotes breast
feeding and the impact of breast feeding for the health of
mothers and babies

develop a strategy to encourage children and young people
to take part in regular exercise

increase and protect access to recreational facilities
(eg public swimming pools and playing fields) regardless of
socio-economic status and level of physical and psychological
ability

promote active travel networks by providing safe
environments for pedestrians and cyclists and ensuring that
there is appropriate support of the built environment by
local and central government

increase the provision of facilities for the combination
of cycling with rail and other travel
As highlighted in the 2009 BMA Board of Science briefing
Transport and health,
taking action to promote healthy
eating and physical activity will have substantial cobenefits for the environment and in tackling climate change.
Policies that promote safe, affordable and accessible use of
26
active transport, for example, will reduce dependence on car
use, thereby improving road safety, air quality, and
increasing physical activity levels.
The 2001 BMA Board of Science report Injury prevention
focuses on people in all age groups and the burden of
mortality and morbidity due to injuries from any cause. The
report highlights the need for injury prevention to be
recognised as a major public health problem as it carries one
of the highest costs in both human and economic terms. The
report made the following recommendations:
Injury surveillance:
Injury surveillance centres should be established in each UK
home country with a remit to collate, interpret, add value
to, and disseminate injury statistics across relevant
stakeholders; these surveillance centres should also have a
remit for research and development of new methods of
surveillance of injuries and injury risk prevalence.
The concept of ‘injury’ rather than ‘accidents’ should be
recognised by the Department of Health and the NHS. The
definition of injury and methods of recording data nationally
require a consensus from all stakeholders to include hospital
departments, police road traffic accident reports, fire
services, the Health and Safety Executive, and others.
The health sector should adopt a primary role in the
collection of high quality data on injuries and their
consequences.
A comprehensive injury surveillance system should include
data from surveys (especially of vulnerable groups) of
exposure to known avoidable hazards (eg dwellings without
functioning smoke alarms, child pedestrian exposure to
nontraffic calmed roads) and of the population at risk of
specific injuries (eg kilometres cycled per person).
Injury surveillance should include an account of the
population prevalence of injury disability. Future national
27
sample surveys of morbidity and disability should clearly
identify those cases attributable to injury (preferably
linked to detail of the original injury event).
Existing data systems concerning injury maintained by
separate agencies should be enhanced and co ordinated.
The accident and emergency minimum data set should be made
mandatory and be consolidated into an accessible national
database. Data collection in primary health care should also
provide an important subset of the overall picture since
minor injuries frequently present in general practice
settings as well as accident and emergency units.
The national sample system of accident and emergency
attenders with home and leisure injuries run by the
Department of Trade and Industry (HASS/LASS) should be
extended to cover all injury types regardless of
circumstances or intent.
National data concerning road traffic accidents (STATS 19)
collated by the Department of the Environment, Transport and
the Regions should be developed to include a standardised
definition of injury severity and be linked to accident and
emergency departments.
Data from coroners’ inquest reports relating to injury should
be compiled into an anonymous standardized national database.
Each of these injury surveillance systems should include
coding of injury circumstances using ICD cause codes and a
measure of injury severity using the injury severity score.
Consideration should be given by the government to placing a
levy on insurance companies to fund research into accident
prevention and interventions, and for insurance companies to
provide mandatory anonymised reports about all personal
injury claims in order to assist in injury surveillance.
Investigations should be conducted to ascertain how this can
be successfully achieved and implemented as policy.
28
Research and development
The total research spending on injury should be increased to
a level commensurate with other major public health problems
and positive discrimination should be exercised to balance
the lack of charitable and private resourcing. A
comprehensive, public, and fully costed account should be
kept of all research on injury (public and private/voluntary
funded).
Systematic efforts are needed to improve the evidence base
for effective injury prevention, especially for neglected
areas such as intentional injury, sports injury and falls,
and to ensure that any widely implemented injury prevention
actions for which there is no current evidence of effect are
subject to urgent formal trials.
New research strategies are needed to:
o
extend the evidence base for effective injury prevention
to include details of cost-effectiveness
o
understand and reverse social inequality in injury risk
o
develop a national plan for multi-disciplinary injury
prevention research including research councils, government
departments and other major research funders
There should be several multi-disciplinary injury research
centres based in UK universities, covering between them the
full range of injury by age group, intent and injury phase
from prevention through to rehabilitation.
The work of, and data emanating from, the present and former
public research laboratories (health and safety, transport
research, fire research, building research) should be linked
to multi-disciplinary injury research centres.
Violence and
Implementation and strategic policy development
abuse
Co-ordinated multi-sectoral action should be focused on the
full implementation of those few injury prevention methods
29
for which there is strong evidence of effect (eg car occupant
restraints, traffic calming, road speed limit enforcement,
smoke alarms, and child proof closures).
Further effort is needed to identify and eradicate avoidable
mortality and morbidity due to inadequacies in trauma
management.
A programme budget should be developed to describe the extent
of public investment in safety and injury prevention for
comparison with other major public health programmes and for
audit against cost-effective best practice.
The NHS should increase its commitment to health impact
assessment and to enforcing health and safety legislation,
especially by:
o
encouraging systems for managing health at work.
o
developing occupational health services and
competencies.
o
improving data on occupational disease and injury.
o
promoting health and safety in the workplace.
An accurate account should be created of the burden of injury
versus other major public health threats in the UK using
internationally recognised methods such as Disability
Adjusted Life Years (DALYs).
The four UK health administrations should jointly review and
compare the resources and priorities that they give to injury
prevention, and identify any specific approaches that have
been shown to be effective.
A national agency should be established in each of the four
home countries following a process of consultation and review
with all interested stakeholders with the following remit:
o
establish a single over-arching national body for
injury prevention and control working in partnership across
government departments.
o
co-ordinate initiatives across all forms of injury, age
groups
o
be responsible for establishing national injury
30
surveillance systems
o
commission several multi-disciplinary academic research
centres
o
develop a national strategic plan for injury prevention
o
be answerable to a single responsible government
minister
At the 2009 ARM BMA members highlighted the need for greater
awareness of violence prevention among the medical
profession. In response to this, the Board of Science
produced a web resource, Violence and Health.
This
signposting provides doctors with an overview of the nature
of violence and outlines how the medical profession can help
prevent violence from occurring.
The 2007 BMA Board of Science report Domestic Abuse Domestic
Abuse aims to raise awareness of domestic abuse as a
healthcare concern and makes the following recommendations:
Healthcare professionals
Addressing domestic abuse in the healthcare setting is a
priority. In order to achieve this, all healthcare
professionals should:
o
receive training on domestic abuse.
This needs to be
implemented on a national scale within emergency medicine
o
take a consistent approach to the referral of patients
to specialist domestic abuse services
o
Mental health
ensure that they ask patients appropriate questions in
a sensitive and non-threatening manner in order to encourage
disclosure of abusive experiences
o
give the clear message that domestic abuse is
unacceptable and not the victim’s fault, and that there are
specialist support services which can provide information,
advice and support
o
recognise that men can also be victims of domestic
abuse and should therefore be questioned if domestic abuse
is suspected.
The UK governments
31
The UK governments should:
o
raise general awareness of domestic abuse, including
for example its prevalence, manifestation and available
support services for victims
o
ensure strategies to address domestic abuse are
explicitly highlighted in their public health strategies
o
develop a more structured and statutory basis for
addressing domestic abuse at the local level in a similar
manner to the policies in existence for child protection
o
recognise that men are also victims of domestic abuse
and this needs to be taken into consideration when developing
policy to address this concern
o
work to identify and combat the barriers to reporting
incidents of domestic abuse. This should help identify the
true prevalence of domestic abuse.
The rights afforded to transgender individuals by the Gender
Recognition Act 2004 should be proactively implemented, for
example refuges must be more accessible to transgender
individuals.
Further work is required in order to:
o
ensure that information about support services is
readily available in healthcare settings such as GP
surgeries, A&E units and maternity departments
o
raise awareness of the scale of domestic abuse in the
LGBT community
o
break down the barriers for such individuals to access
the services and protection they need
o
empower victims to report the abuse to the police.
Domestic abuse education programmes should be implemented in
all primary and secondary schools.
Research
There already exists a good research base on domestic abuse,
in particular with regard to female victims. Further research
is needed on:
Tobacco
o
prevalence of elder abuse
32
control
o
domestic abuse within ethnic minority groups
o
the experience of disabled men who are victims of
domestic abuse
o
pregnant victims of domestic abuse
o
the implementation and effect of the RCOP guidelines on
the routine enquiry of female patients in obstetrics and
gynaecological healthcare settings
o
the number of refuges which exist for male victims
o
the effectiveness of interventions after disclosure of
abuse to healthcare professionals
o
system level changes in healthcare settings that
improve the response of healthcare professionals to survivors
of domestic abuse
o
prevalence and experiences of gay male victims of
domestic abuse
o
prevalence and experience of transgender victims of
domestic abuse
o
effective treatment and interventions for perpetrators
of domestic abuse.
The 2006 BMA Board of Science report Child and adolescent
mental health: A guide for healthcare professionals
examines
the type of problems faced by children and young people aged
five to 17 years and the prevalence of mental health problems
among this age group. The report discusses barriers to the
necessary provision of treatment, including stigma and
discrimination, and makes the following recommendations for
actions:
o
government policies and strategies must be fully
monitored, and data collected and analysed to ensure that
they are effective and addressing need. This information
should be made publicly available and accessible
o
the government must address the shortage of mental
healthcare professionals
o
there must be adequate funding for child and adolescent
mental health services (CAMHS) to ensure that they are
properly resourced and staffed
o
innovative services are needed to meet the needs of young
people, and access to such services must be improved
33
o
it is essential that all professionals providing CAMHS
receive adequate training and support enabling them to
work effectively together
o
the provision of appropriate mental health services to 16
and 17 year olds must be improved
o
collaboration between CAMHS and AMHS must continue and
improve to ensure a smooth transition to adult services
o
the provision of mental health services to looked after
children and young people must be improved
o
the inadequacy of mental health services for children and
young people with learning disabilities must be addressed
o
inequalities in mental healthcare experienced by BME
groups must be tackled
o
barriers to receiving healthcare faced by asylum seeker
and refugee children must be addressed
o
actions must be taken to improve access to mental health
services in young offender institutions, and to tackle
the high rate of suicide among young offenders
o
there is a need to improve public knowledge and
understanding of mental health
o
there should be better provision and dissemination of
information about mental health aimed at children and
young people, appropriate to different age ranges
o
the media should be encouraged to show those with mental
health problems in a positive light, including children
and young people
o
there is a need for more and better mental health
promotion to BME groups in order to address health
inequalities
o
current strategies to address stigma and discrimination
against those with mental health problems must be fully
implemented
The BMA supports the findings of the cross-government mental
Alcohol
health outcomes strategy, "No health without mental health”
that mental health is given the same priority as physical
health and believes that this is a major positive
philosophical shift. In order to help support this report,
the BMA believes that any public health local data
collection/local priorities should be aligned.
34
The BMA Board of Science has published several reports on
tobacco control including Forever cool: the influence of
smoking imagery on young people (2008), Breaking the cycle of
children’s exposure to tobacco smoke (2007), and
reproductive life
Smoking and
(2004).
Tobacco control requires a wide range of behaviour change
policies. The types of policy will depend on the current
levels of awareness of harms, social norms and the
willingness to accept more coercive measures. While tobacco
control policies in the UK are among the most comprehensive
in Europe, more than one in five adults still smoke, and many
people are continuing to take up the habit. The downward
trend in smoking prevalence has also slowed in recent years.
Experiences in other countries suggest that if we do not
sustain and strengthen current tobacco control policies,
smoking prevalence will not only stop declining but could
even start increasing again.
The BMA believes the UK Governments should aim to make the UK
tobacco free by 2035. This ambitious target requires a
comprehensive, adequately funded tobacco control strategy
focusing on tough and progressive measures to reduce the
demand for, and supply of, tobacco products. This requires us
to action the following areas:
Reducing demand for tobacco products
The UK Governments should:
o
prohibit the display of tobacco products at the point-ofsale
o
mandate plain packaging for all tobacco products,
restricting information on the packet to the name of the
cigarette brand, health warnings and any other mandatory
consumer information
o
introduce minimum pricing for tobacco products
o
ensure that taxation on all tobacco products is
standardised and increased at higher than inflation rates
35
Limiting supply to children and young people
The UK Governments should:
o
prohibit the sale of packs of ten cigarettes
o
prohibit the sale of tobacco products from vending
machines
o
reduce the number of outlets selling tobacco
through the introduction of a system of positive
licensing, as is the case for selling alcohol
Educational campaigns and pro-health imagery
The UK Governments should:
o
implement further country-wide media campaigns to
inform the public about the health effects of exposure
to secondhand smoke at home and in vehicles
o
implement mass media, population-wide communications
campaigns promoting antismoking messages and imagery
o
ensure action to limit pro-smoking imagery in the
entertainment media through:

the implementation of programmes aimed at informing
those involved in the production of entertainment media of
the potential damage done by the depiction of smoking

legislation to ensure that all films and television
programmes which portray positive images of smoking are
preceded by an anti-smoking advertisement

greater consideration of pro-smoking content for thde
classification of films, videos and digital material
Supporting smokers to quit
The UK Governments should:
o
ensure smoking cessation services are targeted at high
risk groups (lower socioeconomic groups, pregnant
mothers, those with mental health problems and children
who are looked after by the state, in foster care or in
institutional settings)
o
provide adequate funding for smoking cessation services,
including using two per cent of the revenues raised from
tobacco tax
o
ensure smoking cessation products are available in all
36
the places where tobacco products are currently sold
o
encourage employers to provide access to cessation
services
Helping those who cannot quit
The BMA’s Board of Science supports a tobacco-free harm
reduction strategy as part of a structured approach leading
to permanent smoking cessation. Harm reduction should
therefore only be considered as an interim measure for those
individuals who are struggling to quit, with cessation still
being the ultimate goal.
The Board of Science has published a number of reports with
evidence-based recommendations for action including Under the
influence: the damaging effect of alcohol marketing on young
people
(2009) and Alcohol misuse: tackling the UK epidemic
(2008). The BMA believes a comprehensive, evidence-based
alcohol control strategy is required with action in the
following areas:
Restricting access to alcohol
The UK Governments should:
o
increase and rationalise taxation to ensure it is
proportional to alcoholic content
o
reduce licensing hours for both on- and off-licensed
premises
o
ensure town planning and licensing authorities consider
the local density of on-licensed premises and
surrounding infrastructure when evaluating any planning
or licensing application
Responsible retailing and industry practices
o
The UK Governments should:
o
ensure licensing legislation is strictly enforced,
including the use of penalties for breach of licence,
suspension or removal of licences, the use of test
37
purchases to monitor underage sales, and restrictions on
individuals with a history of alcohol-related crime or
disorder
o
provide adequate funding for enforcement agencies, with
consideration given to the establishment of a dedicated
alcohol licensing and inspection service
o
introduce legislation to prevent irresponsible
promotional activities in on- and off- licenses as well
as the establishment for minimum price levels for the
sale of alcohol
o
introduce legislation to establish minimum price levels
for the sale of alcohol
o
commission further independent research and evaluation
of sales practices, covering all aspects of industry
marketing
o
introduce and rigorously enforce a comprehensive ban on
all alcohol marketing communications
Alcohol education and health promotion
The UK Governments should:
o
commission further qualitative research examining
attitudes towards alcohol use in the UK
o
ensure public and school-based alcohol educational
programmes are only used as part of a wider alcoholrelated harm reduction strategy to support policies that
have been shown to be effective at altering drinking
behaviour, to raise awareness of the adverse effects of
alcohol use, and to promote public support for
comprehensive alcohol control measures
o
make it a legal requirement to prominently display a
common standard label on all alcoholic products that
clearly states:

alcohol content in units

recommended daily UK guidelines for alcohol
consumption

a warning message advising that exceeding these
guidelines may cause the individual and others harm
o
Make it a legal requirement for retailers to prominently
display at all points where alcoholic products are for
38
sale:

information on recommended daily UK guidelines for
alcohol consumption

a warning message advising that exceeding these
guidelines may cause the individual and others harm
o
introduce a compulsory levy on the alcohol industry in
order to fund an independent public health body to
oversee alcohol-related research, health promotion and
policy advice. The levy should be set as a proportion of
current expenditure on alcohol marketing, index linked in
future years
Measures to reduce drink driving
The UK Governments should:
o
reduce the legal limit for the level of alcohol permitted
while driving from 80mg/100ml to 50mg/100ml
o
introduce legislation permitting the use of random
roadside testing without the need for prior suspicion of
intoxication
Early intervention and treatment services
The UK Governments should:
o
ensure the detection and management of alcohol misuse is
an adequately funded and resourced component of primary
and secondary care to include:
 formal screening for alcohol misuse
 referral for brief interventions and specialist alcohol
treatment services as appropriate

o
follow-up care and assessment at regular intervals
ensure the provision of comprehensive training and
guidance to all relevant healthcare professionals on the
identification and management of alcohol misuse
o
increase and ring-fence funding for specialist alcohol
treatment services to ensure all individuals who are
identified as having severe alcohol problems or who are
alcohol dependent are offered referral to specialised
alcohol treatment services at the earliest possible
39
stage
o
implement continual assessment of the need for and
provision of alcohol treatment services
International cooperation on alcohol control
The UK Governments should:
o
strongly support the European Union (EU), World Health
Organisation (WHO) and World Health Assembly initiatives
and policies aimed at reducing alcohol-related harm
o
lobby for, and support the WHO in developing and
implementing a legally binding international treaty on
alcohol control in the form of a Framework Convention on
Alcohol Control
Section 3.29 – 3.37
Living well
Partnership
The BMA believes that self-regulation and emphasis on
with industry partnership with the alcohol, tobacco or food industry has at
its heart a fundamental conflict of interest that does not
adequately address individual and public health. These
industries have a vested interest in the development of
regulatory controls. It is essential that Government moves
away from partnership with industry and looks at effective
Climate
alternatives to self-regulation that will ensure there is a
change
transparent policy development process.
The BMA is a member of the Climate and Health Council which
is an international organisation aiming to mobilise health
professionals across the world to take action to limit
climate change. The Council is calling on healthcare
professionals to sign their pledge calling for urgent
government-led international action on climate change.
The BMA is also working to lobby the UK Governments and the
NHS to:
o
act decisively and quickly to introduce effective action
on climate change
o
develop binding and enforceable carbon footprint
40
reduction guidelines for the healthcare service
o
promote energy efficiency
o
support initiatives to promote the health co-benefits of
actions aimed to mitigate climate change (eg reducing car
use will equate to a reduction in greenhouse gas
emissions, result in increased levels of physical
activity and could also lead to a reduction in accidents
through safer roads and public spaces)
o
regularly review the evidence on mitigation and
adaptation policies and implement those that will make a
difference to the UK and increase or contribute to global
sustainability.
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