Rioting and wellbeing

In a week of rioting it seems strange to be considering wellbeing – something that was demonstrably absent from London, Bristol and Birmingham as EHN went to press. Never-the-less, the concept is now in the policy arena. At the end of last year, David Cameron announced plans to introduce a ‘wellbeing index’ saying that gross domestic product is an incomplete way of measuring a country’s progress.

A key part of the wellbeing agenda is the Department of Health’s new mental health strategy, which aims to achieve parity of esteem between physical and mental health. Wellbeing is also linked with public health planning and is firmly radar for local government, which, for the first time, although it has being doing it for years, is specifically tasked with making people happier.

Meanwhile, the Office of National Statistics is developing indicators to measure wellbeing and social capital. The ONS defines social capital as ‘the pattern and intensity of networks among people and the shared values which arise from those networks’. Drilling further down into the concept it talks of civic participation, such as the propensity to vote or to take action on local or national issues; social networks, such as contact with friends and relatives; involvement in groups and voluntary activities; trusting other people and views about one’s area.

It’s fair to assume that none of these were particularly prominent in those parts of England that rioted. But what of environmental health? Actually, as evidenced by a piece of research commissioned by the Department of Health from the CIEH (see page 10) EHPs have a major bearing on both wellbeing and social capital.

The research, which we will carry a summary of next issue, is based on in-depth interviews with front-line officers and policy makers. It’s not hard to see how dealing with damp or excess cold, reducing neighbourhood noise, tackling fuel poverty and facilitating the removal of trade waste, fly-tipped rubbish and graffiti makes people feel more connected with their neighbourhoods and each other. It’s quite possible that the areas of worst rioting this week, such as Tottenham, Enfield and Peckham, were those with the least visual amenity. Something to ponder on.

 

Tenure of no choice

Twenty-five years ago, in 1986, the first issue of EHN reported on a ‘famine’ in improvement grants. A bold front-page story reported many authorities limiting discretionary improvement grants to disabled or elderly people and long waiting lists. Dr Stephen Battersby, assistant director of the then Institution of Environmental Health Officers, spoke of a ‘savage reduction’ in money available for housing.

At least there were still grants and, until 1988, secure tenancies. But cuts to local authority funding in the late 1980s saw mandatory grants reduced to a trickle, along with council house-building. They were finally killed off in 1996 and not restored by an incoming Labour government.

The Conservatives have returned, in a coalition, and we now have a housing emergency. In many ways it is worse than that of the late 1980s, when a housing market crash and rising interest rates led to a surge in homelessness.

An excellent Dispatches programme, Landlords from Hell (see pages13 and 15) explained how trends uncorrected for three decades have escalated into a fully-blown and wholly predictable crisis. They are – a continuing insufficient supply of new homes, a dearth of affordable social housing and an over-priced and increasingly unattainable owner-occupied sector. The private rented sector – a form tenure for those with no choice – has increased by  40 per cent in the last five years. It now houses more than 3 million people – many wretchedly.

Governments, and local authorities, know that our most aged property houses the most vulnerable; that more than 30,000 people die of excess cold in severe winters, that the only form of private sector rent control is the market and that those who complain to landlords risk, perfectly legally, not having their assured tenancies renewed.

Perhaps the most shocking aspect of Dispatches, was the lack of local authority enforcement activity it revealed – even in a west London borough where hundreds of people are paying to live in garden sheds. A shockingly low level of slum landlords are being bought to book and – coming soon –  insecure council tenancies; ‘social’ rents up to 80 per cent of market levels and even deeper local authority cuts. The housing crisis is going to get worse.

Spotlight on public health

This week Sally Davies, the first woman to hold the post of chief medical officer, appeared before the health select committee, which is investigating the government’s public health reforms.

A heavy winter with the flu convinced her that the UK’s public health structures needed to change. She said the system managed but she was worried about how it would cope with, say, a big E. coli outbreak. The new national public health service, Public Health England (PHE), would, she claimed, bring together the disparate parts of the public health system and lead to better intelligence, surveillance and information gathering. Currently the Health Protection Agency is responsible for infections, cancer registry for cancers and Public Health Observatories for producing public health statistics.

Sitting alongside the CMO was Anita Marsland, PHE’s managing director. How much independence will her service have from the government? Ms Marsland, the former chief executive of Knowsley primary care trust, explained that ministers wanted oversight because public health was akin to ‘defence of the realm’. But she admitted there were professional fears that locating it within the Department of Health might undermine its ability give expert advice.  An executive agency, she argued, was a sensible compromise. The service will be part of its home department but have an ‘operational distinctiveness’.

MPs also wanted to know more about the role of directors of public health. How will the government ensure they are properly qualified? The public health profession feels very strongly that there should be statutory regulation but Ms Davies said the government had not decided. Will, inquired the MPs, directors be ‘underlings’ or will they report directly to the council chief executive? Ms Davies said she could not mandate councils but she expected they would be senior officers and report directly to chief executives. She added that a policy paper due to be published this week would throw some more light on the issue.

Later, Alan Maryon-Davis, professor of public health and EHN columnist, reminded the MPs that PHE will still be a branch of government and the people working in it will still be civil servants. Only time will tell if they will have the freedom to speak truth to power.

Partners in crime

Trading standards and environmental health services (partners in local government since the nineteenth-century) are similar, yet different. Both require ‘boots on the ground’ and local knowledge. Both protect the public from wrongdoing and ignorance in trading, occasionally – though less often in environmental health – in the form of large-scale, organized crime. Trading standards offences tend to be black and white; environmental health ones more often involve shades of grey and judgment calls.

Both professions have come have come under the spotlight with important consultations on their scope and functions, originating from the Department of Business, Innovation and Skills. Reading the documents show that they are perceived very differently by government. The consultation for trading standards, Empowering and Protecting Consumers, is positive in tone throughout with case studies on successful trading standards interventions. It asserts: ‘without robust enforcement of consumer law, consumer confidence could drop, depressing economic activity.

By contrast BIS’s discussion paper on regulation (mainly environmental health) is subtitled ‘freeing up business for growth.’ It dwells on negatives: ‘what aspects of regulatory enforcement are most problematic for you?’ and ‘do you have examples of when you were treated unreasonably?’. Although good environmental health advice and enforcement also nourish healthy and profitable business – for example through food hygiene rating and other accreditation and education schemes – this is not sufficiently appreciated at government level.

Environmental health, unlike trading standards, spread across more than one government department – it crosses from BIS into the domains of health and the environment, food and rural affairs and even work and pensions. In policy term, this is a problem. Each department understands one aspect of environmental health, but not the whole.

However, one can also draw common themes across the two consultations. Both propose new national co-ordination forums – for trading standards a policy board and for environmental health a steering group, liaising between the Better Regulation Delivery Organisation and BIS. This body, potentially, will give the CIEH a new direct line of access to a minister, which can only help in clarifying, at a high level, the unique features of environmental health in protecting consumers, promoting a healthy economy and fostering wellbeing.

 

Footballers versus regulation

The politics of regulatory services are not likely to trouble the front pages of the newspapers, as long as there is a story about a premiership footballer’s amatory exploits. So most people outside the worlds of environmental health and trading standards will be unconcerned that a promised white paper on regulation failed to appear ‘after Easter’.

In May, something caused the white paper to be downgraded to a consultation. It was due to appear in early June. The fact that it did not will not disappoint news editors. But for those interested in the future of the primary authority scheme and of earned recognition, the delay is more than academic. Once the consultation is launched, the CIEH will seek views from its members before responding.

The CIEH believes high standards are best sustained by ensuring organisations accept the need for them; in other words, that they accept the concept rather than have it imposed externally although, in a minority of cases, this may be necessary.

It believes regulatory activity may develop so that it is defined less by a fixed number of inspections and more by a collaboration between regulators and those they regulate. This view is underlined by our feature on health and safety enforcement in Birmingham (see page 10). Far from pestering compliant, low-risk premises with needless visits, which resources do not permit, Birmingham EHOs use intelligence gathering to target the most problematic businesses, backed by workplace interventions including self-assessment questionnaires, spot-checks and, where necessary, formal enforcement.

The CIEH argues that those who can demonstrate regulatory compliance may be entitled to recognition in terms of risk assessment and regulatory oversight. However, essential to earned recognition would be safety assurance schemes audited by third parties. Also, earned recognition should not prejudice the ability of local authorities to use the law where necessary. These matters are of more than academic interest. Sometimes, as shown by the outbreak of E. coli in Germany (page 6), the effectiveness of regulation can be about life and death.

Lessons from German outbreak

The death toll from the E. coli outbreak in northern Germany is mounting. The rare 0104 strain has, so far, caused the deaths of 15 people and made at least 372 people seriously ill in Germany. One woman, who recently visited Germany, has died in Sweden and other cases linked to German travel have been reported in Switzerland, Denmark, France, the Netherlands and the UK.

The German authorities, who fear the number of cases will grow, initially blamed organic cucumbers produced in Spain. This caused a diplomatic row and it now appears a different strain was found on the Spainish cucumbers. Suspicions, however, are still focused on salad vegetables.  The Food Standards Agency is ‘monitoring the situation closely’ but says there is no evidence that produce linked to the outbreak have been distributed in the UK.

E. coli 0104 is extremely rare. There has been only one previous outbreak. In 1994 milk contaminated with E. coli 0104 left 11 people sick, including four who were hospitalised, in Montana, US. But there are precedents for vegetable-related outbreaks. In 1996 infected radish sprouts made 7,966 people ill, with 106 developing haemolytic uraemic syndrome, which can cause kidney failure, in Sakai City, Japan. In 2006 an E. coli outbreak across 26 American states, linked to spinach, caused the deaths of two elderly women and a two-year old child. At least 200 cases were reported, half ending up in hospital.

Then, as now, the key question facing investigators is how the vegetables become contaminated. Ruminant manure, which carries the pathogen, may have come into contact with the produce directly as fertiliser or indirectly after being washed in contaminated water.

A side issue may be organic production. In theory, using animal manure increases the risk of contamination. Investigators may also ask why the outbreak has affected more women than men and more adults than children. According to the European Centre for Disease Prevention and Control, 87 per cent of the victims are adults, and 68 per cent women.  This outbreak of E. coli 0104 will go down in history as one of the worse of its kind.

Thanks to Prof Hugh Pennington for help with parts of this editorial.

Regulations are popular

This month, a new method of policy formulation emerged — ‘crowdsourcing’. The government’s Red Tape Challenge website gathers what it calls ‘regulations’ under six headings — health and safety, environment, equalities, pensions, company law and employment (page 7).

Members of the public are asked to put forward candidates for abolition. After three months, the website explains, ministers will be asked to defend unpopular nominees, or their heads will drop into the basket.

The section labelled ‘equality’ contains a single potential victim, the Equality Act 2010 (a piece of consolidating legislation, unifying previous law). But, surprise, surprise, the first 20 members of the public commenting on the act unanimously defend it, often passionately.

It’s the same in the health and safety section. Fifteen out of 20 respondents are in favour of keeping the measures nominated for the chop. ‘These regulations need to stay!

They have saved countless lives over the years’, writes one. There is universal approval for environmental regulations — 20 out of 20 — combined with puzzlement that measures to protect the environment are presented as ‘red tape’ and anger that the government is considering repealing the Climate Change Act or the Wildlife and Countryside Act. Measures in the employment section preventing people from being summarily dismissed are also vigorously defended. This is not, presumably, what the coalition wanted to hear, having pledged to ‘rip up some of the 21,000 rules’ that it says are ‘holding back business’.

The government has also published 1,294 statutory duties for local authorities for potential abolition (page 5). It attracts an incredulous response, including, for example, the fire safety regulatory reform order (a unifying solution to a previous, rule-based regime); duties to identify lethal hazards under the housing health and safety rating system and to produce homelessness strategies and house-condition surveys.

Is protecting people from being killed by falling down a broken staircase or in a house fire merely ‘red tape’? The response time on statutory duties is only six weeks. Could it be that this, along with the ‘crowdsourcing’ exercise, is merely a crowd-pleasing, PR exercise and that, at the end of both consultations, nothing much will change?

Health bill under pressure

Anne Milton, public health minister, told an audience in Chadwick Court recently that environmental health services do a great job with considerable professionalism and make life better. Environmental health practitioners, she confirmed, are part of the public health workforce.

At the event, the CIEH handed its response to the public health white paper personally to Ms Milton. As well as the keynote speakers, the minister, a former nurse, heard presentations from service heads from large and small authorities, a consultant, a smoke-free co-ordinator and a PhD student. She listened attentively, praising Liverpool’s proactive stance on reducing smoking prevalence.

The minister said that the coalition’s public health policy gains its main thrust from the Marmot review — reducing inequalities — within a free at point-of-use health service, paid for by taxation. This is a sea-change; under a previous Conservative government, as Prof Richard Parish, chief executive of the Royal Society for Public Health observed,
one could not refer to inequalities, only ‘regional variations’.

The event also brought the heads of the Association of Directors of Public Health and the UK Faculty of Public Health to Chadwick Court, making useful professional connections between the NHS and local government

Ahead of of implementation of the Health and Social Care Bill by 2013, health and well-being boards are being set up and the CIEH is addressing how to build up the public health capacity of environmental health, through training and professional development.

This month, the bill became front-page news with the publication of a critical health select committee report and coverage of prime minister David Cameron’s apparent dissatisfaction with the way the bill has been presented to the public. A lull in its progress for further consultation was announced.

Changes to the bill could alter the relative powers of GP commissioning and health and well-being boards and directors of public health. So, the future has become a little less clear. On the plus side, Ms Milton said last week she believes strongly in ring-fenced public health funding and is a champion of local government and environmental health.
So there is much to be hopeful about.

Lansley’s choppy waters

Who could have predicted, when the last EHN was published, a tsunami and nuclear emergency in Japan and an escalating armed conflict in Libya? These unfolding international events have, understandably, removed attention from most domestic concerns, such as the Health and Social Care Bill.

The bill has been going through turbulence. At their spring conference, Liberal Democrats vociferously opposed one of its main elements — the transfer of commissioning powers and budgets from primary care trusts to GPs.

In response, the bill will continue to be amended, with tighter safeguards introduced against private health providers cherry-picking the most profitable contracts and GPs exploiting their position as service commissioners, for financial gain.

The British Medical Association has also voted against the reorganisation prefigured in the bill, although it fell short, this month, of passing a no-confidence motion in the health secretary, Andrew Lansley.

Mr Lansley’s responsibility deal — a grouping of industry representatives and health and food NGOs designed to promote healthier lifestyles — has also been taking a battering.

Six groups in the alcohol sub-group, including the influential BMA and the Royal College of Physicians, say that the government’s ‘deal’ on alcohol pricing, display and labelling, which depends on a voluntary approach, is too weak (see page 9).

Mr Lansley, who has steered Conservative health policy for eight years, would expect doctors to grumble about change and food campaigners to oppose him. However, for the sake of his political credibility, he must be hoping that other strands of his responsibility deal, which also covers food, physical activity and health in the workplace, will not unravel.

It would be a political catastrophe for the coalition if the Health and Social Care Bill failed. The government cannot allow that to happen, so there will be more concessions on the detail, if not the principle, of NHS reorganisation and the opening up of services to ‘any willing provider’.

There has been little controversy or public debate over the bill’s other main component — ring-fenced funding for public health. But the bill will rise or fall as a single entity. Events permitting, it should be an act by this time next year, when parliament dissolves.

Friends of enterprise

Fixed-term parliaments, new constituency sizes, a May referendum on a UK-wide voting system, more powers for the Welsh Assembly — this parliament, which will last until next spring, has introduced masses of political change. At its heart are two large pieces of legislation — the Health and Social Care Bill and the Localism Bill. Together, they will alter radically the shape of central and local government.

Under the Localism Bill, two professions located squarely in local government face the prospect of significant change — housing (new forms of tenancy, funding and regulation) and planning (new powers for communities superceding existing procedures). The Health and Social Care Bill is more significant for environmental health because it could herald a new funding stream but the Localism Bill could also undoubtedly have an impact.

At the Conservative spring conference, prime minister David Cameron banged the drum for enterprise — this is a country of ‘start-ups, go-getters, risk-takers’, he said. And the enemies of enterprise? Bureaucrats imposing rules and regulations, town hall officials with their laborious planning procedures and — a new one — public sector procurement managers, favouring large companies for bids over small ones.

Two of the six principles underlying the Localism Bill have potential implications for environmental health — reducing regulation and diversifying supply in the public sector. But if Mr Cameron sought to portray EHOs as enemies of enterprise this would be wholly wrong because, actually, they are its friends.

As often demonstrated by credible research, small businesses rely upon advice from well-qualified, knowledgeable professionals. EHOs and trading standards officers are business facilitators just as much as regulators.

In its quest for localism, which is not a bad direction of travel, the government tends to define excessive bureaucracy as an opponent of progress. But it’s worth remembering where the measurement regimes, performance indicators and targets came from that restricted professional initiative and slowed down decision-making. It was central not local government.

Are the town halls being made to pay for errrors that originated at the centre?