RSPH Public Health Manifesto 2019

Introduction

The Royal Society for Public Health (RSPH) is the world’s oldest public health organisation and is dedicated to protecting and promoting the public’s health and wellbeing. We have over 6,500 members across the health and public health workforce, including those working in the NHS, universities, charities, local authorities, and industry. The proposals put forward in this document have been informed by consultation with our membership and backed by the public.

The purpose of this document is to advise on what are the most pressing public health challenges for today and the future, and how the any future Government should respond to champion the public’s health. With a general election campaign underway, we call for all political parties to adopt the policies outlined in this Public Health Manifesto.

Underpinning this document is the understanding that while high quality healthcare will always remain a priority, an individual’s wellbeing is largely the result of wider determinants. These include the social and environmental forces that shape people’s lives, such as work, housing and advertising – factors that between them are estimated to account for 50% of an individual’s health and wellbeing, compared with the 30% attributed to behaviours, and just 10% attributed to direct medical care. We also identify a new emerging force which we call the digital determinants of health.

Dealing with these wider determinants and the public health issues we outline requires real commitment from any future Government and the cuts in funding to local authorities in recent years must be reversed in order to support much needed public health programmes.

We believe that the next government should show ambition and boldness in utilising taxation, regulation and legislation – time and again these have been proven to be the most effective tools for driving sustained improvements in population health. These are measures that require work that cuts across departments, where health and wellbeing becomes a consideration in all policymaking.

Reducing health inequalities

There are wide inequalities in the distribution of good health across the UK population. The gap in healthy life expectancy between the least and most deprived areas in England during 2015 to 2017 was 19.1 years for men and 18.8 for women.

Social deprivation involves a variety of wider determinants that hold individuals back, who might otherwise be able to pursue healthy activities. These include factors such as work, wages, education, housing and debt. Our own research has looked into place as a determinant of health, ranking UK high streets by the health-determining features of their immediate surroundings, such as the clustering of fast food outlets or betting shops in some areas. We found that the less healthy the high street, the more likely it was to be in an area of high deprivation and lower life expectancy.

These social determinants of health have an impact on physical health. Research into the affordability of food suggests that healthier diets are consistently more expensive. This could be one reason why obesity prevalence for reception and year 6 pupils in the most deprived areas was more than double that among those from the least deprived areas in 2017/18.

Financial security also has a connection with mental health. Our own work on the relationship between debt and health found that nearly three quarters (72%) of the electorate who had used credit in the previous 24 months said they had spent more time alone because they couldn’t afford to participate in their normal activities.
Recommendations:

An urgent review of the current government formulas used for allocating local authority funding, so that local need is properly address and accounted for.
Changes to NHS commissioning allocations for CCGs so that a higher share of funding is targeted at areas with high inequalities, as suggested by The Kings Fund.
An independent regulator for the public and private rented sector, to ensure housing is at a high standard for healthy living.
For the Financial Conduct Authority and the Advertising Standards Agency (ASA) to prevent lenders from sending direct marketing for further loans to individuals who have struggled to make repayments on their current loans.
Provide local authorities with the power and support to restrict the opening of new betting shops and other unhealthy outlets where there are already clusters.

The digital determinants of health – an emerging public health issue

The online setting is taking up an increasing portion of our lives, and the pathways by which it can impact on population wellbeing will only multiply as we go forward. Therefore, any prevention strategy that aims to remain responsive to the public health issues of the future must build in an explicit goal of tackling the digital determinants of health.

An emerging issue in this area that has stood out in our own work is the effect of social media on mental health and wellbeing. The All Party Parliamentary Group on Social Media recently found that more than a third (38%) of young people reported that social media had a negative impact on their self-esteem. This is a new challenge for our society.

We need to understand how young people are dealing with experiences related to depression and anxiety, such as body dissatisfaction, low self-esteem and the ‘fear of missing out’ (FOMO), particularly when demand for mental health services are at an all-time high.

The growing role of social media also presents challenges to how health and wellbeing information is communicated to the public. This spans multiple aspects of health, but is particularly true in regard to vaccinations, and the prevalence of anti-vaccination messaging on online forums. Our research has found that two in five parents are exposed to negative messages about vaccines on social media.

While we retain an excellent national immunisation programme, persistent myths such as ‘vaccine overload’ play a role in vaccine hesitancy, and international precedent demonstrates we cannot afford to be complacent.

Digital determinants of health, however, include a variety of developments in the online world that are not limited to social media. Research by the Gambling Commission has found increasing adult participation in gambling online, while almost a third of children have paid for gambling-like products such as ‘loot boxes’ in video games.

The indirect effects of the increasing presence of the internet in how we organise our lives must also be considered. Our own research, for example, has looked into the rise of online shopping to the detriment of our high streets. More empty stores mean fewer incentives for people to leave the home and get active, at a time when obesity levels are higher than ever before.

Recommendations:
The following recommendations touch on different health issues, but are our key recommendations relating to the digital determinants of health. They include:

A Social Media Health Alliance, funded by a 0.5% levy on the profits of social companies, to review the growing evidence base on the impact of social media on health and wellbeing and establish clearer guidance for the public.
A duty of care on all social media companies with registered UK users aged 24 and under in the form of a statutory code of conduct, with Ofcom to act as regulator. The plans for this have been outlined in the Online Harms White Paper, but the regulator must take into account the mental wellbeing of users.
Input from DHSC into the development of the independent regulator outlined in Online Harms White Paper, to ensure that online information on vaccinations is at a high standard.
A continuation of positive social media campaigns regarding the value of vaccinations, to improve the chances of people seeing accurate and reliable immunisation messaging online.
The Government should commission robust, longitudinal research, into understanding the extent to which the impact of social media on young people’s mental health and wellbeing is one of cause or correlation.
A mandatory levy on the profits of gambling companies, to fund treatment centres and research into treating and preventing gambling harms.
An Online Sales Tax to address the mismatch between online and physical businesses. Currently, business rates are based on the value of physical premises which puts high street retailers at a huge disadvantage.

Adopting a health in all policies approach

Reversing funding cuts to local authority and public health teams is an essential prerequisite to a successful prevention programme. We argue, however, that the next Government should be far more ambitious. We advocate a longer-term project to make population wellbeing the focus of future budgets from the Government.

Recommendations:

The next Government should aim to move away from the description of societal goals in terms of income and economic growth, and towards a targets framework based on promotion of population wellbeing. There are several options the Government should consider, including but not limited to:

The implementation of a Health and Wellbeing Budget. We point to New Zealand’s 2019 Budget as an example of this, though the chance for innovation in this approach is very much open.
The development of a Health Index that is inclusive of health outcome measures, modifiable risk factors and the social determinants of health. This a project that is currently recommended by England’s former Chief Medical Officer Dame Sally Davies. This Health Index would either replace, or be considered alongside, GDP for how the future Government measures progress.
Learn from and build on the Well-being of Future Generations Act in Wales, with a view to a similar act to be implemented in England.

Wider public health workforce

The agreed definition for the wider workforce is, ‘any individual who is not a specialist or practitioner in public health but has the opportunity or ability to positively impact health and wellbeing through their paid or unpaid work’. Approximately 20 million people in England have the potential to be part of the wider workforce.

Of those people, we have identified occupations already engaged with the public’s health and enthusiastic to do more, covering three quarters of a million people. Examples of these ‘early adopters’ include Fire & Rescue Services, Health Trainers, Allied Health Professions, Community Pharmacy, and Housing Associations.

These groups have the potential to provide much needed support to our 40,000 core public health workers. This would require adjusting the work they are already paid to do; however, there is already abundant evidence that these workforces are enthusiastic about playing a greater role in prevention. With the development of Integrated Care Systems, highlighted in the Ten Year Plan, and the development of Primary Care Networks, the harnessing of the wider workforce offers real opportunities for furthering community support and wellbeing.

Expanding the wider workforce requires a strategy for their development and inclusion in the work of prevention. This is also a cost-effective prevention strategy, as it involves plugging into a workforce who are already in employment. The value and public health potential of this workforce cannot be left out of conversations on population wellbeing, and we believe this must be recognised in the Green Paper.

Recommendations:
We recommend that the Government pursue:

Joint working between Local Government Association, Public Health England, Department of Health, Health Education England, public health organisations and employers to drive forward wider workforce planning and capacity building for health and wellbeing.
Education and training for the wider workforce ensuring that they are equipped with the requisite skills, competencies and confidence to deliver public health across a variety of settings.
Identification of services that can be commissioned and delivered by early adopters in the wider workforce. These could include behaviour change programmes, point of care testing and social prescribing.

Protecting the Public’s Health

Improving the delivery of and confidence in vaccinations

The UK retains an excellent national immunisation programme relative to the rest of the world. However, the loss of our ‘measles-free’ status is deeply concerning, and there is room for improvement both in terms of delivery and ensuring the public have full confidence.

A recent report from the National Audit Office pointed out that uptake for almost all childhood immunisations has consistently fallen in the last seven years. Reasons for this trend highlighted in the report include the fragmentation of the immunisation system brought by the 2012 Health and Social Care Act, as well as a lack of clarity from the NHS England on the standards expected from general practice when it comes to immunisation.

Recommendations:

Funding for new local immunisation co-ordinators, informed by a review into whether they are best placed in primary care networks, CCGs or local authorities. These co-ordinators would be responsible for supporting the planning, reporting and training of the immunisation in their patch. They could also be a local champion of vaccines for parents and patients who have any questions or concerns.
A review looking into whether uptake could be increased by allowing vaccinations in more spaces outside of general practice, such as community ‘pop-up clinics’ or strengthening the role of community pharmacy for adult vaccinations, such as flu, pneumococcal and shingles.
A HPV vaccinations catch up programme for boys aged 13-18. Boys aged 12-13 are now set to be vaccinated alongside girls; however, we need to ensure we cover those who have initially missed out, as we did with girls when the programme was first introduced.
Input from DHSC into the development of the independent regulator outlined in Online Harms White Paper, to ensure that online information on vaccinations is at a high standard.
A continuation of positive social media campaigns regarding the value of vaccinations, to improve the chances of people seeing accurate and reliable immunisation messaging online.
Greater support for schools teaching the science and value of vaccinations and how to be critical of information found online. This would be in line with the Department for Education’s latest draft of the new statutory RSE guidance.

Air Quality

Approximately 10% of UK lung cancer cases and 3,600 cancer cases annually are caused by outdoor air pollution (PM10 and PM2.5). For those affected, air pollution reduces life expectancy by an estimated 11 years.

The Conservative Government’s 2019 Clean Air Strategy was a welcome first step, but does not go far enough in its targets for air quality levels. For example, the current concentration limit for PM2.5 is 2.5 times the WHO guideline limit.

Recommendations:

That the next Government introduce new limits for PM2.5 and PM10 concentration levels that are in line with the WHO guidelines, and make a legally binding commitment to meet these levels by 2030.

Improving Food Safety

The Food Standards Agency (FSA) estimated in 2015 that food-borne illness costs the economy and individuals around £1 billion each year.” Making sure that working systems are in place to prevent the contamination of food from allergens and pathogens can have a huge impact.

There are signs we losing progress in this area. Just over a third (37%) of necessary food standards interventions were carried out by local authorities in 2017-18, down from 43% in 2012-13. As well as providing support to help food safety work continues at a high standard, it needs involve new enforcement powers and regulation to keep up with our changing food environment.

Recommendations:

Grant local authorities the power to issue fixed penalty notices for breaches of food hygiene standards.
Make it mandatory for restaurants to display food hygiene ratings in their windows.
Make it mandatory for online food platforms to display food hygiene ratings and allergen information for included providers. This would standardise work already being done. Just Eat, for example, now publish hygiene ratings for every restaurant on their platform, while customers on Uber Eats can input their allergen restrictions to help them choose a provider.
The inclusion of allergen management in Food Hygiene Rating Scheme.

Infection Prevention and Control

In the last decade, there has been a big increase in the number of people having tattoos, piercings, electrolysis and acupuncture in the UK. In our own research, we have found that almost one in five people who have had a tattoo, cosmetic piercing, acupuncture or electrolysis in the last five years have experiences negative effects.

The legislative environment has struggled to keep up with this evolving environment, and despite some parts of the UK taking steps towards improving how these procedures are regulated, there remains no standard legal requirement for technicians delivering these procedures to hold an infection control qualification.

In fact, anyone can purchase specialist equipment online to carry out tattooing or piercings without the necessary training or qualifications in how to use them. There is also no legislation covering other equally invasive treatments, such as dermal fillers.

Recommendations:

For the next Government to make non-surgical cosmetic procedures illegal for under 18s.
Businesses to only sell tattoo and piercing equipment to individuals who can provide documentation evidencing their registration or licensing with their local authority.
All UK health systems to bring in a requirement for an infection control qualification as part of licensing and to review the procedures included within special procedures legislation.
Infections linked to special procedures to be included in the list of notifiable diseases that must be reported to local councils or local health protection teams.
All UK governments to review their special procedures legislation to include non-surgical cosmetic procedures such as dermal fillers.

Tackling obesity

The percentage of adults classified as obese has been on the rise over the past few years. Last year, Public Health England found record high levels of severe obesity for year 6 children. This presents a significant challenge to population health and wellbeing. We need to act to ensure people are more active and eating healthier.

In order to encourage greater physical activity levels at a population level, and in a way that accrues to people across the socioeconomic spectrum, there is a need for wider environmental change.

Recommendations:

A 9pm watershed on the advertising of products high in fat, salt and/or sugar.
Licensing powers of local authorities to be explored for implementing price and location restrictions, and the restriction of fast food restaurants from areas near schools.
Greater promotion of the Healthy Start scheme. The scheme gives low income families access to fruit, vegetables and cow’s milk, all of which are necessary for healthy development, however, more than 130,000 eligible households have missed out.
The sugary drinks levy to be extended to other high sugar foods.
Mandatory calorie labelling for all businesses in the out-of-home sector, covering all food and drink (including alcohol).
Safe and segregated cycle lanes separated from traffic-heavy roads to be established, tracking popular routes to schools.
The Department for Transport to propose a revised funding settlement for active travel. The next Government must increase spending on active travel now, and provide future funding that is sustained, long-term, and increases as a proportion of overall transport spend over time.

Children’s oral health

The evidence on the efficacy and safety of water fluoridation is unequivocal. It is a cost effective intervention that would yield immediate cost savings, and RSPH regards it as the principal measure which can improve the oral health of children and the nation as a whole.

Water companies and local authorities should work together to ensure it is implemented without delay, with a focus on areas with high prevalence of tooth decay.

Recommendations:

Emulate the Scottish Childsmile project in the rest of the UK. This initiative, involving the delivery of supervised tooth brushing in schools, has been evaluated extensively, found to have a hugely reduced poor oral health in children, and awarded Best Practice status by the EU commission for doing so. As a home-grown prevention initiative with a watertight evidence base and which pays for itself within the lifetime of a government, opportunities for roll-out of this programme to the rest of the UK should be explored.

Tackling the harm from drugs

Drug policy
RSPH supports the advancement of evidence-based harm reduction strategies in drug policy, and the rolling back of counter-productive criminal justice approaches which have been at best ineffective at reducing harm from drug use, and at worst responsible for exacerbating that harm.

Recommendations:

Transfer lead responsibility for UK illegal drugs strategy to the Department of Health, and more closely align with alcohol and tobacco strategies.
Decriminalise the personal possession and use of illegal substances.

Tobacco
The percentage of the population who smoke has seen large falls in the last four decades, but has declined at a slower rate over the last few years. Smoking remains the leading cause of premature death and tobacco control policies require further progress if we are to achieve a ‘smokefree generation’.

Recommendations:

A ‘polluter pays’ levy on the tobacco industry, designed to deliver a fixed sum annually to the Government to be used to fund measures to encourage smokers to quit and to discourage youth uptake. A recent YouGov poll of over 12,000 respondents found that almost three in four (71%) supported the measure.
Further increases on the tobacco tax escalator of 5%, with an additional increase of 10% for hand-rolled tobacco (HRT).
Provide support for e-cigarette manufacturers to have products that meet the requirements of the Medicines and Healthcare products Regulatory Agency. This will help e-cigarettes to be prescribed by NHS GPs for those wanting to quit smoking.

Alcohol
Alcohol consumption is set to cost the NHS £17 billion over the next five years. Liver disease deaths have increased by 400% since 1970, now the only major cause of death in the UK which is rising.

Recommendations:

The roll out of minimum unit pricing for the rest of the UK.
Increasing alcohol duties by 2% above inflation in order to provide funding for alcohol treatment services.
Greater powers for local authorities to control when and where alcohol can be sold, including through making public health a licensing objective.
Improved training for healthcare professionals in discussing alcohol consumption with patients.

Funding prevention services

After almost a decade of central government cuts to funding, total service spending by councils has fallen by 22.3% between 2009-10 and 2016-17. This includes spending on planning, housing, transport, environmental and social services.

Public health grants to local authorities, too, have been cut in real terms by 3.2% a year between 2013-14 and 2017-18. This is despite research showing that public health interventions are cost-effective, cost-saving and ‘excellent value for money’, when considering their preventative effects.

Since the transfer of public health to local authorities in 2013, the vast majority (80%) of indicators in the public health outcomes framework have shown either no change or an improvement (with one exception being in aspects of sexual health ). Considering the scale of cuts to local authority spending, these figures suggest that public health is most effective in the hands of local authorities and would significantly benefit from greater local authority funding.

The announcement of a 1% real-terms increase for the public health grant in the recent Spending Round was an initially promising development, however it does not go near the funds needed to return to 2015/16 levels and above. Moreover, if more services are added under the fund, it may not even be a real-terms increase at all.

Particularly concerning is that local authorities that are most dependent on government grants, who are much more likely to cover deprived areas, have seen the largest falls in service spending. Recent analysis from the Institute for Public Policy Research has found that £1 in every £7 cut from public health services has come from England’s ten most deprived communities - compared to just £1 in every £46 in the country’s ten least deprived places.

Recommendations:
To remedy this, the next Government should:

Take seriously the call from Public Health England (PHE) for a framework of funding evaluation that cuts across departments and recognises the significant long-term benefits of public health programmes.
Restore the £1 billion cut from the public health grant by 2020/21.
Outline plans to cover the funding gap of £8 billion that councils in England face by 2025, currently forecasted by the Local Government Association.

RSPH urge all Political Parties to adopt the policies identified in Public Health Manifesto show the ambition and boldness necessary to prioritise, protect and promote the public’s health.

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