Readings for a new #publichealth councillor

Over the past few weeks, as the local government year starts to ramp up, a number of newly elected councillors have asked me for some basic reading on Public Health.  This is my suggested list for them.  Perhaps you could suggest some?

 

Dear Councillor,

Here is as  promised at the induction seminar the self-reading guide to getting your head round public health. There are many more topics than those below, and I merely set out some of the more important. Perhaps the best thing is to come and talk and if you want material on specific issues like drugs, or children and young people, I will supply you with a list.

Public Health principles: the very basics

Public Health is about working with populations, out of a framework of analysis, evidence and an intention to promote and protect their health. This involves working with a range of determinants of health from education levels to health behaviours and the various threats and hazards to our health which arise from the environment (naturally occurring diseases) and from the products and progress of contemporary society (air pollution for example). Poverty and inequity lurk behind most poor health like an eminence grise et horrible.  In my own mind, neither individual nor societal explanations for the burden of disease and ill-health and poor flourishing our society carries are sufficient. Both must be held in dynamic tension to elucidate what the issue is and what we can do.  Equally, Public Health is not, to me, purely a science. It is an application of various sciences and art.   Epidemiology and Leadership, Evidence and Influencing come together or lie ineffective. They are a blend, if you will.

We now have three out of 6 short e-learning video presentations on what public health is on Herts Health Evidence https://www.hertshealthevidence.org/ and more will be added soon.  You should be able to access these free by requesting an account at the site.

The Open University has a variety of free online courses here http://www.open.edu/openlearn/body-mind/health/public-health

If you wanted a book, then my best bet to start would be Virginia Berridge’s Public Health: A Very Short Introduction Oxford University Press, 2016. Let me know if you have difficulty finding this, I can track it down easily in London next time I’m there. There are many more choices after that from classics like Donaldson and Donaldson’s essential public health through to Geraint Lewis’ Mastering Public Health which is to my mind far more useful than Donaldson and Donaldson.

English Policy on Public Health and NHS (because Wales, Scotland and Northern Ireland all have very different systems.)

This is invaluable https://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england

The easy read on the last seven years of policy history (about which I could talk without cease and without notes) is this from the Kings Fund https://www.kingsfund.org.uk/projects/verdict/has-government-delivered-new-era-public-health and this set of videos https://www.kingsfund.org.uk/audio-video/public-health-spending-roi . A further read is here https://www.kingsfund.org.uk/publications/improving-publics-health

I think you can trust the King’s Fund an independent health think tank. It’s well respected

Responsibilities of Local Authorities

In terms of the key Public Health Responsibilities in local government, the choices are endless so I would go for the list below

  1. The basic guidance (there is an awful lot more) http://www.fph.org.uk/uploads/DPH_Guidance_Final_v6.pdf
  2. The Local Government Association www.local.gov.uk publications are always extremely valuable and I suggest these two as starters https://www.local.gov.uk/lga-annual-public-health-report-four-years
  3. https://www.local.gov.uk/public-health-transformation-three-years

But there are many more from the LGA, and the LGA website has an invaluable series of publications for local authorities on public health.  I am of course biased but the Association of Directors of Public Health blog has a series of very short pieces. http://www.adph.org.uk/category/pblog/ and it’s worth checking our updates here http://www.adph.org.uk/

Mental Health

The Local Government Mental Health Challenge website is a very useful starting place to some of the issues http://www.mentalhealthchallenge.org.uk/  I find this guide on system wide (population or public health approaches to mental health) commissioning principles useful http://www.jcpmh.info/wp-content/uploads/jcpmh-publicmentalhealth-guide.pdf  and Finally, the Mental Health Foundation’s report is very good https://www.mentalhealth.org.uk/publications/better-mental-health-all-public-health-approach-mental-health-improvement

Health Inequalities

The Marmot Report is probably the best starting place https://www.local.gov.uk/marmot-review-report-fair-society-healthy-lives but there is also a social sciences answer to it too, which makes specific policy proposals, some of which we have adopted in Herts https://www.britac.ac.uk/sites/default/files/If%20you%20could%20do%20one%20thing%20-%20full%20report.pdf

The NHS Sustainability and Transformation Plans

I would look no further than the reports from The King’s Fund https://www.kingsfund.org.uk/topics/sustainability-transformation-plans

I suggest pick these and come and have a coffee and ask any question you like, or we can even do a seminar for your group or whoever.

Happy reading.  I should finish on one note. If you are confused, then you join the rest of us. If it all makes perfect sense, then you really have missed at least one important thing.

Jim

 

 

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Skills for leading the system: Law training for leaders in #PublicHealth

I apologise in advance that some of you will find this (uncharacteristically short) post irrelevant. Some of you will find it boring.  I warrant, though, that just a few of you will find this salient and important.

On 13th October 2017, another one day masterclass for senior Public Health leaders on how to navigate the legal concepts they need to be effective in local government will run in London.  The course is free, it explicitly intends to give public health people working in local authorities the key background to the law and practice issues affecting them, and it already filling up.

Skills for managing the system

Sounds off-putting, doesn’t it?  But this course is in its fourth year and everyone I know who has been on it has found sooner or later they needed what it gave them: enough knowledge to navigate a complex issue.

People will spend a day with several senior and very experienced lawyers, getting detailed guidance, able to ask questions, and going away with a resource pack which one delegate from a previous year described as “incredibly handy: I never knew this stuff. I now know I need to know this stuff.”

The course will be delivered pro bono again this year by several amazing lawyers ; including this year Judith Barnes a senior partner at Bevan Brittan and people like Luis Andrade from Herts County Council and the Society of Local Government Lawyers.  It is a joint venture with ADPH.

There are still a few places left on this, contact magdalena.vandersteen@adph.org.uk to book.

It’s my fault, this idea

This course was my idea. I’m not going to apologise for inflicting it on people.  And after several requests from people to tell them why I came up with this idea, I’m sharing with you my reasons. And they’re pretty simple.

Why on earth did you come up with this?

First, local authorities run on the law.  I speak from experience of over fifteen years in local authorities. They are created by Parliament, they have many legally binding processes and a constitution, and legal issues from procuring services to making decisions are all bread and butter for senior people in local government. And these are things the public health training scheme never prepared you for.

Second, if you want to do something in local government, you need to know the legal powers and duties you have, and how to navigate them.  For example, I use a particular power in the Local Government Act 1972 to fund District Councils to do public health work which saves me a significant amount of process and cost.  Planning, Licensing,  dealing with Anti-Social Behaviour, dealing with air pollution: they all require an understanding of the legal principles.

Third, you have to know what makes a system works if you are going to use that to the benefit of the public’s health, whether by making the system work more effectively or bypassing it.

Fourth, public health leaders need to be equipped with the same knowledge as their peers to be effective in working with them.

What use has it been?

I’ve just finished a round of telephone conversations with a small sample of people who have been through the course. The common benefits people identified from being on this programme are those below:

  • Knowledge – knowing enough to know when they need expert legal help
  • Agility – being able to identify potential solutions
  • Being on a level playing field with other senior managers who know this stuff
  • Confidence that they can promote the public health work and defend the budget and team
  • Ability to recognise a potential problem and deal with it early

So, if you are going on the next masterclass, enjoy. If you haven’t, get in quick.

 

 

 

 

 

 

 

The ACMD Report on Drugs Commissioning: Back to the Future?

This week the Advisory Council on the Misuse of Drugs published its report on the Drug and Alcohol Commissioning system in England.   Government hasn’t responded yet, and to be honest much of the trade press and media gave it very little coverage.   A good and thoughtful blog piece on this report and some of the issues it raises by Will Haydock rewards reading.

This report is a mixed bag but we shouldn’t ignore it

I’ve heard a number of policymakers and thought leaders be frankly dismissive of this report.  And I think that’s a shame.

There are some real mixed aspects of this report. First what I think are the downsides:

  • It feels like an approach of suspicion towards local authorities. They more or less ignore the joint Public Health England, Local Government Association and Association of Directors of Public Health report on drugs commissioning. Were the findings of that report, that actually a number of things which needed to change were being changed, just inconvenient to their narrative, one wonders? Picking one set of what’s gone before (back to pre-2012) while ignoring the other (the ADPH/PHE/LGA Report) just makes it easier to dismiss your report, without looking to see if there’s anything salvagable of value in it.
  • The report doesn’t engage with the substance of the Government’s new strategy other than demanding that it does several things they want. It doesn’t welcome what’s good in the Strategy and doesn’t really critique what’s problematic.  How can we take seriously a report about commissioning which doesn’t engage with a strategy whose impact on that commissioning system will be wide-ranging? On any view, that’s a mistake. And it makes it even easier to dismiss this report.
  • The report doesn’t engage really with the financial climate for the public sector, preferring to take an uncritical and somewhat rose-tinted view that everything will be better if we just hand drugs back to the NHS. This is naïve in the extreme given where NHS finances are now.
  • A nostalgia for the pre-2013 days which is not only unrealistic but shows some convenient amnesia of some of the things before 2013 which were not good. Putting drugs services back into the NHS is not going to protect them, that is a completely false hope in my view.  The report feels like it wants to hark back to a presumed Golden age when the National Treatment Agency  (remember them) ran things, and the NHS had control of drug and alcohol commission. Oh it was so much better, then. Except it wasn’t

In addition, there are two things in particular I regret about this report.  The first is it’s a pity they don’t mention any of the cuts to Local Authority budgets really, except some mention of the Public Health Budget and I think they take an overly selective reading of their own 2015 survey.

The second is that this is yet another report, giving yet another – sometimes overly partial – narrative.  Some have said this is really a narrative on behalf of the provider sector.  Writing reports feels like a rather dated tactic these days.  Getting together and discussing constructively issues between commissioners, providers and researchers is the approach that’s needed. Writing disgruntled reports back and forth seems to slightly miss the point in a system that needs us, more than ever, to work together.

Finally, I think they don’t sufficiently factor in the significant changes in demographics, use and epidemiology since 2012.  The drug and alcohol world is a different one in terms of trends, users, evidence and policy.  Going back to 2012 is not the answer. Arguing for the best funding and best commissioning and provision we can get now, is.

The report more or less lacks the nuanced and balanced understanding we have a right to expect from an organisation which should know better, and which should have done its job better.

So, we have a report which, given what I’ve said above, would be easy to dismiss, lends itself in the way it has been put together to not being taken seriously, and looks to some people as naive and partial. I think we need to look beyond all that and really think through this report.

The signals in the noise: Some good points

In the midst of what feels like a great deal of noise and lament, there are some good things and some sensible points. They do point out some areas where the system needs to work better.

They acknowledge some good things about the changes since 2013 – but spend little time telling us what they are before proceeding almost straight away to say everything else has more or less gone downhill.  I can’t help thinking they’re making a selective and overly rose-tinted reading of recent history.

My own view of where we are is rather more nuanced than this report. Some things are better, some things are more challenging, and some challenges endure – we didn’t have research right in 2012, for example, We still don’t have it right now.  The idea that the drug treatment system was ideal or even “really great” before 2013 is an unsupportably revisionist view of history.

Worth looking at the key conclusions and recommendations

It’s worth looking at their key conclusions and recommendations because while there are some things in here I find really problematic, there are some areas where they have a point and we need to listen.  It’s just a shame that rather than talk to commissioners, they feel it’s more appropriate to shout at them.

ACMD Report Conclusions and Recommendations

My take on these

Conclusion 1

Despite the continuation of the ring-fenced Public Health Grant to local authorities until April 2019, reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas.

 

 

This is the only point where they really acknowledge reductions in funding, but their point is reductions by commissioners, not reductions by government.

More and more people are saying that the government needs to reverse the cuts to public health, and these cuts are increasingly damaging. It would be good is ACMD felt able to join that call. They didn’t. I think that’s a mistake.

Recommendations

National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.

 

Mandation of services seems to be everyone’s knee-jerk solution to this, so we mandate more and more of a smaller and smaller pot of money. All that does is make the job of running a public health system undoable.

Mandation is not the answer to this, reversing the cuts is the answer. Government has decided to impose cuts across the public sector, the drugs sector is no more special than any other part and cannot be exempt. Are drugs services more important than safeguarding children?  The more you mandate, frankly the more you pass the problem elsewhere to the rest of the system. More and more mandation is an appealing, but ultimately false, solution.

National government’s commitment to develop a range of measures which will deliver greater transparency on local performance, outcomes and spend should include a review of key performance indicators for drug misuse treatment, particularly those in the Public Health Outcomes Framework (PHOF), to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.

 

 

 

 

This recommendation doesn’t feel well thought through, which suggests the authors don’t understand the reporting which exists.

Reporting is already transparent with lines explicitly on drug misuse within the reporting on the ring fenced grant. The Public Health grant already has 26 lines of reporting, including substance misuse, for around £50m in my Authority’s grant. By comparison social care reporting lines are less than 10 for £300m . Benchmarking service costs is already done by CIPFA and can be publicly gained from government data on the Public Health grant. This recommendation completely misses the point.

The local health and wellbeing board or local drugs board and local authority are the places to consider and address “falls in treatment penetration”. This recommendation seems to want to re-instate the performance management of the old National Treatment agency.

There is enough transparency in the PHOF and other indicators, combined with the new strategy and guidance. We don’t need yet another additional range of measurements.

Conclusion 2

The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing.

 

This is too sweeping, even if they have a point. Resourcing is not the only issue, even though it is an issue. Models of care, changes in demographic patterns and population need get very simplistic analysis in this report in some places.

The PHE and LGA report identified that commissioners have said in a number of places services needed reconfiguration to meet changed need and changed models of service. This conclusion just ignores the joint PHE, LGA and ADPH work on drugs commissioning.

There is another opportunity for ACMD to argue that the public health cuts need to be reversed here.

Recommendations

National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced and ineffective services.

 

 

What do they actually mean by this? I don’t know. I’m not sure they do either.

This isn’t benchmarking, this feels like an attempt to set a national tariff or a minimum payment or go back to the market management arrangements of the old National Treatment Agency. That could have some merit, or it might not. But this recommendation should have been clearer and more focused about what mechanisms and structures they feel will help.

The Government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead or commission a national review of the drug misuse treatment workforce. This should establish the optimal balance of qualified staff (including nurses, doctors and psychologists) and unqualified staff and volunteers required for effective drug misuse treatment services. This review should also benchmark the situation in England against other comparable EU countries. This is a helpful recommendation. Most commissioners I know would welcome a workforce review of skills and workforce needed for the future including workforce redesign. Simply basing workforce on models of workforce pre-2013 is not the answer to the changed epidemiology, policy and financial climate
Conclusion 3

There is an increasing disconnection between drug misuse treatment and other health structures, resulting in fragmentation of drug treatment pathways (particularly for those with more complex needs).

 

This is nothing new, and was recognised long before the new system came into place. We need to do something about it though, and they do us a service by reminding us.

The new drugs strategy, The 2017 revision of the Orange book clinical guidelines and the recent PHE guidance on co-existing morbidities actually provides opportunity to advance this agenda, as does the mental health crisis care concordat.  Much of this disconnection is because the system as a whole is fragmented. Putting treatment services back in the NHS won’t solve that.

Recommendation

Local and national government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).

This is a mostly sensible and welcome recommendation. Inclusion in STPs and strengthening links good, and making links with CCG and other plans. But has ACMD forgotten we have Health and Wellbeing Boards? (Ok, they’re not always wonderful either, but please, don’t just ignore an entire sector.
Conclusion 4

Frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates drug treatment recovery outcomes.

 

 

Procurement can be a two-edged sword, if not done well and purposively. It can be a great tool for developing quality, and it can be a disrupter. The key thing here is to do it well and sensitively.

This conclusion could have been more nuanced, and identify in much better detail some of the ideas and suggestions for making this happen. There are numerous reports of places where re-procurement has been necessary to secure service improvement.

Recommendation

Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years, with longer contracts (longer than three years) and careful consideration of the unintended consequences of recommissioning. PHE and the Local Government Association (LGA) should consider the mechanisms by which they can enable local authorities to avoid re-procurement before contracts end in systems that are meeting quality and performance indicators.

 

In and of itself this isn’t the answer. Long contracts with a complacent provider don’t help anyone. I think the report though is calling for some kind of stability and relationship, and that makes sense. A key issue for us as commissioners is how we work well with the rest of the system to do that. To my mind this is a call for better system leadership and commissioning, and seen in that light we should give it serious thought.

Procurement is part and parcel of the legal framework of commissioning and providing services, many other areas have used it to improve outcomes and there is evidence that this has happened since 2013 on a range of public health services.

Procurement conducted well can remove unintended consequences and be a tool for improving quality, cost and outcomes. Done badly it can have the effects the report laments.

Systematically seeking to avoid re-procurement is both unlawful and seeks to thwart the intentions of value for money and effectiveness that procurement can, used well, address.

Conclusion 5

The ACMD is concerned that the current commissioning practice is having a negative impact on clinical research into drug misuse treatment across NHS and third (voluntary) sector providers. Many treatment providers are third sector and current research structures are not designed to recognise them. System churn due to recommissioning and reduced resources mitigates the stability and infrastructure required for research.

 

This is not new. Drug treatment services in many places have long been outside the NHS, and issues of research capacity, research structures and even things like provision and management of Specialist Registrars and Speciaist Trainees have been issues. We do need to ensure these issues are addressed constructively.

 

 

 

Recommendation             

The Government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field. Any group set up to work on this should include:

·       government departments;

·       research bodies such as the Medical Research Council (MRC) and the National Institute for Health Research (NIHR); and

·       other stakeholders.

A sensible recommendation which we should support , but it should also include commissioners.  The lack of mention of local authority commissioners, once again, feels sadly like distrust.

 

 

 

 

 

 

Chemsex: Why should it be a Public Health issue?

 

I don’t know about anybody else, but I can’t help thinking that the issue of chemsex is one we are still not really getting our act together on.  I claim no specific expertise here, but what I do know is this issue is impacting on the health of our population, and an already vulnerable one at that, so we need to act. And I have several friends and colleagues from across the country -the youngest 24 and a student, the oldest 50 and a professional in the City, whose processes of getting out of the harm they’ve come to I have helped with.

We seem to have depressingly little in the way of national leadership or action on this from the Public Health community, with the work of some dedicated individual clinicians and community activist -step forward David Stuart and 56 Dean Street, Greg Owen, Matthew Hodson, GMFA , James Wharton, MenRUs, Burrell Street Clinic for their Safer Chemsex Kit and a few others being most visible. I have provided links to several pieces of this work in the footnotes, but let me also direct you to  London Friend’s work on LGBT drug use and recommendations for treatment services .  I hope anyone I have missed off will forgive me.

It is simply unacceptable for the skills and resources of the Public Health profession to be absent from this issue.

I was discussing this today at another meeting. I said to a colleague from another agency “people say we don’t have a problem locally” and before I could continue to say “and they’re wrong” he interjected, “they should just open grindr, it’s everywhere.”

The use of some kind of substance to enhance sex is known and common throughout history (drinks while dating?) And if people are fine about that and use without harm, then I don’t feel it’s my business.  But recently the phenomenon of chemsex has become a bit better known than it was. A search of MEDLINE and PSYCARTICLES when I was doing a quick review to inform this blog, after removing duplicates, found in 2014 3 papers, a search for 2017 found 48 papers so far in the health and psychological literature.

Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine. Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles.

While it may be more of a scene for gay men, bisexual men and heterosexuals do it too. What will that pattern will be in two years time? We know that trends started by gay men sooner or later get picked up by the wider heterosexual world, or am I just remembering disco through rose tinted (glitter encrusted) spectacles? (Showing my age there.)

Increasingly, use of chems or drugs is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play.  From the many paper available, I have a few which I think resonate. Weatherburn et al[1] identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido. Media attention[2] and the interest of the scientific press[3] seems to have been somewhat limited to date.

The increasing intelligence from reporting by clinicians and community groups of problems presenting from chemsex is concerning. From understandable motives – socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time[4] , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.

Dedicated professionals like David Stuart and others working on this issue[5],[6] have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences[7] in Something for the Weekend and the associated meda reporting[8],[9]have gone some way to cast some light on this as an issue which needs addressing.

Parties are not the only places, however, where chemsex is becoming an issue. Increasing use of chems with sexual hook ups means some men may rarely have sex sober. It’s not just physical risk, but psychological. Intimacy may become associated with being high, and for some, dependent on it.

Prevalence

A 2014 BMJ editorial suggested a minority of men engage in chemsex[10] but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England[11].

Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile[12]. Estimates of prevalence vary in recent reports[13] but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.

Harm

There are also some people who seem to be able to use drugs regularly without seeming to come to harm. If people genuinely can do that safely, and we can help them successfully avoid harm, then my interest ends there. But many do come to harm, and it’s those who experience harm in any form I’m interested in here. And the harms from chemsex can be wide.

Whether or not this is a minority phenomenon in terms of the population, the harms to some users are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex[14].

What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible. Some of the documented and reported harms are shown in Table 1 below. But this isn’t exhaustive.

Table 1: Harms from chemsex

Physical Health ·      STIs, HIV and other Blood borne viruses

·      Physical effects of comedowns

·      Risks to circulatory system from injection

·      Respiratory risk from frequent use

·      Risk of death from overdose

·      Disrupted sleep patterns, anorexia, weight loss

·      Impaired immune function

 

Psychological/Mental Health ·      Use of chemsex to facilitate social contact and overcome loneliness, isolation

·      Coping mechanism for stigma and homophobia

·      Impact on coping skills, sleep, employment, cognitive functioning

·      Impact on relationships of becoming habituated on having sex while using drugs

·      Psychological impact of financial problems from financing habit

·      Impact on identity integration and acceptance

·      Bereavement from people in social networks dying as a result of G

Social health ·      Group identification

·      Coping with stigma

·      Holding down a job and responsibilities

·      Risk of debt and homelessness

·      Criminalisation for possession of drugs and sometimes dealing

 

Public Health Issues

Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.

I have spoken, written and presented elsewhere on how the need to ensure LGBT populations are able to live happily and successfully across the lifecourse must be a public health issue[15],[16]. So I won’t repeat that here. One of my worries is that chemsex for some can hamper or impair that process.

The mental health impact of being unable to have sex or be intimate unless high presents a number of challenges. But there is another set of issues. If some gay men use chemsex to cope with stigma or feelings about being gay, that must be seen as potentially problematic. It is a commonplace in psychology of LGBT populations that a key task is identity integration and acceptance[17]. Theory and evidence assumes that identity integration and assimilation is crucial to health and wellbeing outcomes for gay men across the lifecourse[18],[19],[20]. It is assumed to be especially important to ensure inclusion for LGBT people in education and employment. If chemsex disrupts such processes, or means a population or sub-population of gay men can only feel good enough about themselves where mediated through drug use (either individual or in groups), there may be significant avoidable psychological morbidity as a result. If what Wharton says about younger gay men finding it easy to get into this scene is true, then that has worrying implications about the ability of those men to form attachments and integrate their identity as they grow, with potential maladaptation and poor coping and mental health across the lifecourse[21].

Policy frameworks and action

While chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it[22]. There remains no coherent public health response. Community harm reduction approaches[23] including safer injecting kits[24] are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart[25] There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence is still crucial to developing action on this, and we need to find ways of making sure we capture and factor that into response planning, on a more agile basis than we sometimes do.

What can be done?

A range of action is needed, and this needs to be revised as we know more. I group suggested actions under domains here.

Domain 1: Establishing prevalence and incidence

  1. We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
  2. Including and using community intelligence in this development will be crucial
  3. Asking about chemsex use should become a routine question in sexual health services on the electronic patient record

Domain 2 : Harm Reduction strategies

  1. We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
  2. The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
  3. Support harm reduction including continued information and kits to reduce harm
  4. Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
  5. Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
  6. Sex venues should consider placing information on chemsex and where users can get help.

Domain 3: Service response and readiness

  1. Most chemsex users don’t find drugs services resonate with them on the whole. We need to identify what drugs services and sexual health services can to do address this and roll it out
  2. Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
  3. Those services should become skilled in particular identity and lifecourse issues facing gay men
  4. Services should consider whether they can recruit people recovering from chemsex harm to work with those seeking support
  5. Drug services should consider as part of this work both the LGBT supplementary guidance of the NEPTUNE programme work on NPS ,the London Friend work on drugs services and LGBT populations and the work of David Stuart

Domain 4: Developing consensus on interventions

  1. Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies, and keep this under review.
  2. Learn from the work being developed by the London Chemsex Network as part of this

Domain 5: Community resilience

  1. LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
  2. Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex

 

[1] http://sti.bmj.com/content/93/3/203

[2] http://www.newstatesman.com/politics/health/2016/04/what-chemsex-and-how-worried-should-we-be

[3] https://www.newscientist.com/article/2140756-what-is-chemsex-and-why-is-the-uk-government-worried-about-it/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611333/

[5] https://gregowenblog.wordpress.com/2015/10/17/chemsex-the-film/

[6] http://www.davidstuart.org/

[7] Wharton, James (2017) Something for the Weekend: London : Biteback Publishing

[8] http://attitude.co.uk/exclusive-former-british-soldier-james-wharton-opens-up-about-addiction-chemsex-culture-is-now-gay-culture/

[9] http://www.telegraph.co.uk/men/the-filter/11942081/Nine-things-you-should-know-about-GHB.html

[10] http://www.bmj.com/content/351/bmj.h5790

[11] http://sigmaresearch.org.uk/files/report2014b.pdf

[12] http://www.bbc.co.uk/news/magazine-35976705

[13] https://www.lambeth.gov.uk/sites/default/files/ssh-chemsex-study-final-main-report.pdf

[14][14] http://www.bmj.com/content/351/bmj.h5790

[15] https://www.slideshare.net/jamesgmcmanus/british-psychological-society-sexuality-and-wellbeing-symposium-a-public-health-perspective-on-lgb-populations

[16] https://www.slideshare.net/jamesgmcmanus/lgbt-public-health-agenda-idahot-2016

[17] https://msu.edu/~renn/BilodeauRennNDSS.pdf

[18] https://pcilab.ucsc.edu/wp-content/uploads/sites/472/2017/06/Hammack-et-al-2017.pdf

[19] Hammack, P.L (2009) The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course New York: Oxford University Press

[20] https://www.ncbi.nlm.nih.gov/pubmed/12666737

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215279/

[22] http://www.independent.co.uk/news/uk/home-news/drugs-treatment-strategy-government-criticism-problems-campaigners-a7841986.html

[23] https://www.gmfa.org.uk/Pages/Category/safer-chems

[24] https://www.menrus.co.uk/drugs/introduction/

[25] http://www.davidstuart.org/care-plan

A bit of thinking on saving the country £200m…and much more…

The opinions which follow are entirely personal and do not claim to reflect those of or have endorsement by any organisation.

Folk will doubtless have read of the proposals by the Chancellor to cut £200m from the local authority public health budgets in year. We still await detail of what is proposed.

David Buck, from the King’s Fund, gives an excellent breakdown in today’s LGC (Local Government Chronicle) of why this is much more serious than initially suggested. David says that

“many unanswered questions remain, including how this relates to the transfer of children’s services from the NHS to local government planned for October. This will be worth more than £800m each year.”

David recounts that the proposal comes on top of a standstill in public health funding. Secondly, he says it seems to contradict the commitment to Prevention echoed in the NHS Five Year Forward View, and then, thirdly, reminds us that many of the services commissioned by Public Health are commissioned from the NHS. Despite the recent commitment to protect the funding of the NHS. This will impact on the NHS, and directly.  But David’s most telling point is to warn of wider consequences:

“Locally, it could easily create perverse incentives that lead away from integration. Why would clinical commissioning groups enter into pooled budgeting arrangements with local authorities, when they know their funding is safe and sacrosanct but local authorities’ money is not?”

David’s piece is here, and is well worth a read. Equally, Keith Cooper’s editorial comment in the same issue is extremely good at highlighting how this proposal will have a wider impact than just local government.

Apart from being really quite incisive sets of comments, it’s heartening how the local government press has taken enthusiastically to the potential which public health has as part of the local government family.

We are, I think, just beginning to articulate the possibilities that prevention could deliver for better lives, better health and a more sustainable public purse. It’s entirely right that the Government of the day usually has expected and should expect its public officials to deliver the “Four Es” – Economy, Effectivness, Efficiency and Equity – from public spending, especially in an era of austerity. I just think that there are much more effective and far-reaching ways of doing it than applying a poorly thought through £200m clawback.

This was highlighted yesterday and this morning with the launch of the ‘Smoking Still Kills’ strategy where the argument for preventative services is expounded; and the success to date of reducing costly and painful death and disease from tobacco is evident. Giving preventive activity time to embed really can yield differences. Locally our new approach to drug recovery is reducing the spend on residential rehabilitation and the cost to social care. There is money to be saved here, but we need to do some lateral thinking. Prevention can be made to work, but only if we see it as a system, and work as a system.

There is no way the current £200 million proposal can happen without impacting on the NHS

At an estimated 7.4% of in year public health spend, it is highly unlikely that Local Authorities will be able to achieve efficiencies across all areas of current public health spend without affecting the statutory Public Health services (e.g. sexual health, health checks ) or other NHS services which constitute a considerable proportion of the public health grant and service investment (e.g school nurses, health visitors). David Buck points out that not cutting NHS servics is a Government Manifesto commitment.

Page 38 of the Government’s Manifesto reads

“We will support you and your family to stay healthy. We are helping people to stay healthy by ending the open display of tobacco in shops, introducing plain–packaged cigarettes and funding local authority public health budgets. We will take action to reduce childhood obesity and continue to promote clear food information. We will support people struggling with addictions and undertake a review into how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back in to work.”

As a public health professional this is inspiring. In fact, we have two social enterprises in Hertfordshire who spend all of their time getting people into work after battling drug and alcohol dependency. And they do a good job. I was hoping to expand this ethos more widely to mental health and other long term conditions but without being able to use public health money for investment, it’s unlikely the money will come from anywhere else. The current proposal  to cut £200m is not the way to help the local health economy’s existing plan for delivering those commitments, or prevention savings more widely.

Alternative Efficiency Proposals in the short term

Some colleagues and friends have been in discussion with me. And I have shamelessly purloined some of their ideas here. (You know who you are, and thank you.) If £200m really has to be saved from NHS spend this year, (and remember much public health spend is actually spend on the NHS) then I think  a more constructive approach would be to:

  1.   Give Hospital Trusts a £200m target to reduce avoidable costs from procurement and agency staff commissioning. The ‘Carter Report’ widely trailed in the news today suggests that Hospitals may not be gaining the £400m in procurement and agency savings alone they could reap in these areas[i].
  2. Give NHS Trusts a £200m target to reduce ‘interventions of limited clinical value’ in NHS provision. The Academy of Royal Collages Report (November 2014) suggests that 20% of all health care activity is effectively over-treatment as it  ‘brings no benefit to the patient’[ii] .This could be done without harming health outcomes.
  3. Introduce a Sugar Duty at 20 pence per litre in England[iii]. The impact nationally over twenty years would be to:
  •  reduce the cases of diabetes by just under 50,000
  • prevent almost 9000 cases of cancer
  • reduce strokes and cases of coronary heart disease by over 33,000
  • save the NHS at least £15million a year in healthcare costs for treating those diseases.
  • improve the quality of life for tens of thousands of residents.

4. Introduce the levy on the tobacco industry called for in Smoking still kills. This could pay for the cost to local government of social care, cleaning, litter, smoking cessation, tobacco control and other measures; and the cost to the NHS of treating diseases attributable to smoking like COPD, cancer and even Diabetes as identified by the recent report of the US Surgeon General.

All of the first 3 measures above are evidenced based (references in footnote below), would reduce costs, would bring clinical benefit to patients, would  improve health outcomes for citizens and would improve NHS productivity without reducing its capacity to prevent future demand. The fourth measure is argued for in Smoking still kills.

Additional Efficiency Proposals in the medium term

Obviously we would and could make further savings by doing things differently. Preventing diseases from escalating or worsening and treating as quickly and cheaply as possible continue to be options which we can explore further. Here are just five of my list of candidates for saving money while improving health:

  1.  Make greater use of pharmacy for minor ailments and long term conditions
  2. Drive down the cost of consultations and polypharmacy in multimorbidity by delivering models of care which address multimorbidity per se, rather than accumulating niche guidelines, treatments and consultations for multiple individual conditions. And please don’t say we’re doing that. The last 29 conversations I had on this with clinicians had one consensus point: we can do a lot better.
  3. Invest in self management – there are promising models here.
  4. Identify early high risk of escalating disease and disability and keep people at optimal levels of functioning through good pathways and practice.
  5. Learn from the five best countries in the world about keeping people with long term conditions economically active (eg in the workforce).

There are, with some thought, good implementation science and hard work, many places from which we could save sustainable sums that will be multiples of £200 million. And we could improve health into the bargain.  It wont be overnight.  The way to do it is focus the public health, local government and NHS workforce on prevention and quality, not chasing short-term cuts. You don’t even need to invest here;  just don’t cut to transform and save.

 

 

 

 

 

 

 

[i] Academy of Royal Collages (2014) Protecting resources, Promoting value: A doctors guide to cutting waste in clinical care http://www.aomrc.org.uk/publications/reports-a-guidance?view=docman

[ii] http://www.bbc.co.uk/news/health-33071066

[iii] The Children’s Food Campaign has  published a tool that allows people to view the impact a sugary drinks duty could have in their local area. The figures, available on www.childrenshealthfund.org.uk  show that the introduction of a duty on sugary drinks could reduce rates of diet-related diseases by tens of thousands, as well as save the NHS and public health budgets in England £300 million over twenty years.

 

 

Leadership…it’s not all transformational in public health

I don’t know about anyone else but when I was training in Public Health, things like leadership education were largely missing. I was lucky to get onto the national Public Health Leadership programme over a decade ago now, and even luckier to have other training.

And yet leadership is an absolutely central function in public health, and leadership across systems especially. http://www.slideshare.net/jamesgmcmanus/leadership-and-ds-ph-update-oct-2014

You’ll be aware from a pile of postings, articles, slideshares and other stuff that I have an interest in (obsession with?) leadership in public health.  This is at least partly due to reflections on my own failures and a desire to try and get it right. And it’s partly due to my training as a psychologist. In the last few months I have reflected again on my own leadership roles but also have done a number of sessions for new public health leaders.

One thing I have noticed is that Transformational Leadership models seem to be the flavour of the month at present. I have found transformational leadership models, especially when adapted to the public sector (e.g. the work of Beverley Alimo-Metcalfe on local government) very helpful. Try these links for more reading on this:

The last link above on Post Francis enquiry approaches is especially interesting.

But there are some challenges with Transformational Leadership models, before we go running down the road to apply them in preference to anything else:

  • Some commentators feel transformational leadership is better in an organisation. When you work across a whole system, as public health leaders need to try to do, there are additional behaviours, styles and tactics you need, and you need to flex your style much more as a system leader across different organizational cultures than just transformational models would suggest
  • Transformational leadership training is not always good at explicitly integrating the scientific background of public health senior roles with the leadership tool portfolio they need
  • There is a very thin line between transformational leadership and dictatorship or bullying. Engaging people in your system and organisation is hugely important with transformational change and leadership and rightly many researchers are now emphasising this.  Beverley Alimo-Metcalfe, who created among other things the Local Government Transformational Leadership questionnaire, has spent a great deal of time on the importance of this.

Dennis Tourish’s new book The Dark Side of Transformational Leadership (Routledge, 2014, £24.99) is a salutary read on the strengths and weaknesses of Transformational Leadership as a model and theory.  He presents a significant amount of research on transformational leadership and case studies. The book has a good style, discussion questions and reflection questions and if you’re looking for a CPD text then do yourself a favour and give it a go.  Even if you only read the last chapter on new styles of leadership and better ways of thinking about leadership.

But he makes a range of important points that Public Health leaders who are attracted to transformational styles:

  1. Tourish spends some time in his book looking at the (usually catastrophic) consequences of leaders with vision whose decisions have not been challenged or helped to mature by being reflexive or open to others. There is always the potential that leaders in trying to transform do as much harm as good
  2. Unregulated power in a leader (I’m sure many of us have been there, on whichever end) is not a good thing and a key part of leadership in a system is about being held to account as much as holding to account. Leadership seen as service, as enabling a system is better at that
  3. Transformational leadership models in people who think they know better than anyone else can become a justification for arrogance. Public Health has not always been a stranger to that arrogance about its role, importance and abilities.
  4. Transformational leadership which is all about the leader and not about the team or organization or structure can have, like any leadership style, profoundly negative consequences on others.

Transformational leadership has its place. But if you are a public health leader in a system which doesnt want you, or is dysfunctional, or where others think they know your public health job better than you, then I am unsure that transformational leadership is the solution. An adaptive style which enables you to assess situations and use a menu of styles, tools, tactics and mechanisms is more likely to be helpful.  And indeed much recent research on leadership seems to be showing that across mutliple context systems that works. http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

Trying to apply this is an interesting process, and I sat down one day with a group of colleagues when we were sharing challenges and perspectives. I have some rules of thumb on leadership which seem to be working at present:

  1. There is no Perfect style or perfect leader:
    • I will never be a perfect leader and there will always be fallout from what I do. But thats not an excuse not to do better. Doing better is the whole point
    • There is no single model of leadership which is right.
      1. The best “model” (or rather frameworkk which enables us to take different bits of different models) I can find at present is that of distributed, adapted leadership which is about leading systems. It takes in a range of elements including the transformational. You can find my presentations on this here   
      2. Leadership is a journey towards being authentically you and truly effective. That journey never ends and we can all always do better
  2. As with all public health, science and art must be held in dynamic tension to be effective and authentic
    • The science of leadership, good solid psychological science, needs to be taken seriously. But the more science I read on leadership, the more I realise it’s just as much art as science.
  3. Sources of reading and learning
    • Do yourself a favour and check out reviews in decent journals like  Harvard Business Review, The Psychologist or Management Today rather than buying blind in a book shop
    • Rarely trust anything you buy in an airport book shop
    • Do Read Harvard Business Review (even if you do find it in an airport bookshop)
  4. Models can be deceptive
    • If a model or course sounds too good to be true (you will become an amazing leader in one day) it usually is.
    • Be sceptical of people who espouse a model of leadership but have never led in your context. (If you haven’t spent a day in local government, how do you truly understand the context? .)
    • Models will change and my learning and style should change as knowledge develops
    • Over-reliance on one model is usually unhelpful because it limits your grow
  5. Think of Frameworks not models
    • A framework tells you what sets of thing you may need to be doing rather than prescribing “this is how you do it”. These rules of thumb are my framework
    • Ethics, Values, Vision and Context are as much a part of any good framework as tools and tactics and inventories
  6. Leadership cannot be context independent and be effective
    • Leaders are set into not apart from the contexts they serve (so the “independence of the DPH” needs to be handled carefully here).
    • Beware the “high” doctrine of leaders as great individuals. The context and the people make the leader as much as the leader.
  7. Leadership is a service to the common good or it is nothing
    • Leadership is a portfolio of influencing skills and tactics to get to the common good (ok this is my bias, but I bet you have one too)
    • That desired good will always be changing, like everything in life
  8. As the recent Kings Fund report suggests, as a leader across systems you need to be comfortable with chaos. Please note that my and your leadership style creates at least some of that chaos anyway!
  9. Dont expect people to be gentle and trusting of your leadership style if you cant spend some time being gentle and trusting of you and them
  10. Four golden functions: Nurturing, Guiding, Healing and Reconciling and Discipline (I dont mean sticks I mean holding a line and standard to keep people to) are important in leadership, and you need to be a receiver as much as a giver of these
  11. Leadership always has a dark side or down side
    • It may be just the fallout from your style. It may be just the dysfunction of being human and imperfect. But leadership ALWAYS has a down side, at least for some of those your leadership touches. If we don’t deal with this openly and work out what to do along the journey then our leadership is unethical.

Anyway, these are the things that help me. It may be different for you. Let’s help each other on our journey.

Influencing and tactics – some thoughts

We’ve been busy writing a review of what we’ve done and achieved since 1st April 2013, and from that several things have emerged :

  1. Our decision to invest in programme management infrastructure working alongside technical public health capacity was the right one. We have delivered over 143 workstreams in public health since April 2013, according to our overview spreadsheet (also known as “the workbook of Aaaargggh”.) This has won us a reputation for getting on with things.
  2. There are a few areas we need improvement in, like continuing the upward trajectory on chlamydia testing and so on
  3. The skill set needed to do public health in local government is a hybrid – technical skills + programme management + influencing + system wide working
  4. You need to have a game plan- a simple statement of where you’re going

And we had a fantastic Association of Directors of Public Health conference earlier this week. I got to spend an entire day with my  Cabinet Member, listening, learning and sharing together.  A really important thing to do. And her perspective had a good degree of helpful challenge from someone with significant political experience.  Which led me to reflect on and refresh my game plan. Sometimes the best conversations we have are not in the formal briefings but in the informal 1-1s we have over a meal, a coffee, or the brilliant café just along from local government house in Smith Square when we’re there for meetings or events.

The ingredients of game plan delivery

In order to get your game plan delivered, you need a series of things. Programme management, leadership and a host of other things.  But most of all you need people who believe in what public health can do at all levels, especially when there are sceptics or you come up against people who disagree with you, for whatever valid reasons.

I suspect I take a slightly different perspective on influencing from some colleagues in public health, and this obviously reflects my learning by experience (good and bad) having been a local government officer or worked in national roles with local government for more of my career than I was in the NHS. So, for what it’s worth, here’s my ramble  about this. I know lots of people may well disagree with me but the approach below works for me.

Influencing and “speaking out”

It seems to me we use this as a profession far too liberally.  The issue of “speaking out” is something which can be done in a range of ways, and sometimes speaking truth unto power is better done in quiet rooms though sometimes it must be done forthrightly in public. In both circumstances it is better done when all the public health family of agencies can see eye to eye.   But the point is not that agencies in the public health family “speak out” together. Writing letters to The … (insert name of newspaper or journal)  has to rank as one of the most ineffective influencing tactics of all time.  It’s done by most tacticians in my experience to underline an existing influencing tactic, and then sparingly. Useful as part of a tactical plan as one mere strand but in and of itself faintly pointless. And frankly, the immature party political “yah boo” noise coming from some of us just makes us look ridiculous. The trouble with schoolboy shout and pout politics is that you are forever seen as an outsider. You may feel good , but you are almost certainly not doing good.

There’s more than one way to influence and speak out, and the public health family could learn some valuable tactics from Stonewall, for example. Stonewall spoke positively and articulated how and why, things should and could be done, and built relationships. It’s easier to build alliances than being seen as a constant critic.  It also means when you do criticise that your criticisms will carry more weight.

Game plans national and local

For me the first rule of influencing is a game plan others can buy into. That may mean you need several iterations of game planning before you get where you want to be.  It also means relationships with others are key. And as a public health family some of our agencies excel at this. Others need to do more work on that. The differences between RSPH, FPH, ADPH and other agencies – however important the agencies are to us in what they do – can seem bewildering to people outside public health.  I look forward to RSPH, FPH, SSM, UKHF and ADPH bulletins because they give me valuable stuff.  And if you have to look up what the initial mean I think that only reinforces my point about bewildering array of agencies.

But there is an achingly heartfelt prayer for Christian Unity I love in the Scottish 1928 Prayer Book which prays “Give us the grace to lay seriously to heart the great dangers we are in by our unhappy divisions.”  I pray that in the family of public health agencies our differences do not become unhappy divisions. But it is time to lay to heart the need to work and understand together, and indeed our agencies are meeting and working together. In policy terms when we’re all asking government for something different, it makes the job of government to do public health more complicated than it needs to be. 

There is one enormous benefit to having such a number of agencies – if we really get together we can constitute an effective policy network at national and local level. Policy Network approaches are things I have written about before and have been enormously successful in some areas of policy. The public health family of agencies could be such a policy network. There are groundrules about how these work well. I’ve been part of one for 13 years which has lobbied on equality issues and recently by working directly with people who we have historically seen as opponents we have actually secured very quietly a change in national policy. And I have the gift of some new friends and colleagues I admire and respect. On our own, we would never have done this. I’ll write more about policy neworks another time but there is a respectable literature on it, especially in the Journal of Public Administration.

Articulate the possible

And this brings me to my second golden rule of influencing from experience: articulate the way forward in a way which makes it clear to do and buy into.  Two proverbs I try to bear in mind and I forget the authors – “if you can’t explain something simply, you don’t understand it well enough” and ” to complicate is easy, to make simple difficult.” Our challenge is to do that.  One of our Cabinet Members says that I can in the right time and place be ” a cantankerous git”  and “I love it”  (I prefer to think of it as robust and thorough). He can read a forty page document and spot what’s missing in ten minutes. And he can sniff the absence of a clear, simple, well articulated plan in the air long before it arrives.  I always think of him and three others when getting people to put together a plan.

Relationships

But the single most effective tactic in influencing I have ever used is investing time in building relationships. And if you want to do that with elected members please leave any ideas that your primary tactic is negotiating skills. Because that bombs in my experience. Mutual respect, an acknowledgement of their importance, an acknowledgement of my role, and a lot of effort on my part to get inside their heads and work out what they are trying to do is the key. And that has always paid off.  And they make just as much effort in my experience to work you out.  Whether their working you out is supportive is not is partly down to how well you engage from the start.

When members “get” the public health agenda, things start to motor. That may come down to some negotiating, but frankly it’s usually the last tool out of the bag. Articulate the outcomes and reasons in ways that resonate with their agenda. If you cant do that, then find a member in another authority who will mentor you.  DsPH as chief officers need officer and member mentoring often because we haven’t had the experience of working with members that other more long-standing chief officers have.

It may sometimes come down to you giving advice that a course of action would not be right, and sometimes even having to be robust in that advice, but the importance of DPH and members “getting” each other – a mutual understanding of each other’s agendas, limits and game plans – is the crucial thing. And being able to express public health ambition in the language which meets the ambitions of members is important.

A kick up the noughties

A next rule of influencing is be ready to renew and change your tactics regularly. Dominic Harrison the Director of Public Health for Blackburn with Darwen said at the PHE conference that “we have a definition of health coined in 1948, competencies set in the 1970s and we call ourselves change agents.” That comment made me go “ouch” and hug him at the same time.  He has a point, expressed it well and it resonated round the room with many. There are many ways to advocate change, and “speaking out” if it becomes a default just means you get isolated by the system. Our challenge is to be effective at being change agents, and so we need a large repertoire of influencing methods.

The independence of the DPH

The new system makes us an advocate and advisor for public health. That doesn’t mean we are independent of our authorities and in the NHS independence for non medics like me was really, I feel, a myth. I would argue it’s also a distraction. Constitutionally and legally being a Chief Officer in a local authority means a number of things about sharing corporate responsibility for the running of an authority.  (That’s written into my appraisal .) That provides me with far more opportunities to influence for public health than any speaking out would ever give. We are not, as DsPH, independent voices from our employers. We need to live with that and work out tactics for influencing which work within that.  Independent advocates eventually get streamrollered or ignored.

My ability to speak out now is no more compromised than it ever was in the NHS. As a non-medic (and remember there have been test cases on this) one did not have in either Agenda for Change or local authority contracts anything like the same contractual freedoms and leeway our medical colleagues would have been able to lay claim to about writing independently to the BMJ, for example. Speaking out in some ways is a very good sign either that relationships have broken down or the person speaking out doesn’t have the skills to influence in a different way.  Going back to Dominic Harrison’s pint about being change agents, the world has changed and we need to change how we change it.

So I think there are different styles needed for DsPH who, like me, are one of six Chief Officers charged with corporate responsibilities and those DsPH who are not chief officers.  And there is a nuance of approach we need to develop for those DsPH who are in local authorities which are uncomprehending, indifferent or where there are issues, however they arose.

Building the influencing skills

We should be supporting each other through providing leadership and influencing skills while the faculty nationally also does its lobbying and speaking out. For me that leads to two things in particular:

 a)    How we skill up DsPH to do their influencing role effectively and to take a leaf out of their more experienced chief officer colleagues in some respects.

 b)    being clear on boundaries, tactics and occasions.

 The upshot of this is, I guess, that I am saying we need to get much more sophisticated individually, as a profession and as system about this.

There are small groups of Directors, Consultants and others in public health who meet in learning sets around the country.  The ones I know about are about how people work as a network to influence and get what they need to deliver public health.

Values

A final word about values. If all this seems devoid of values, then you are missing the point. The whole point of this is that values are at the centre. If you don’t have values, why influence anything? Values are essential.

Public Health values about social justice, equity and so on are or ought to be at the ground of what we do as public health professionals. But just don’t assume that can only be expressed in one type of philosophical or political language. Public Health Influencing is done in context, and different contexts require different styles and languages.

For me, Catholic Social Teaching is a fundamental set of values which at least in part determined why I went into public health in the first place. You can read more at http://www.catholicsocialteaching.org.uk   And if you don’t believe that can be applied in a range of contexts including the corporate world I invite you to check out Blueprint for Better Business,http://www.blueprintforbusiness.org/Home which numbers some of Britain’s biggest corporates in its values-based agenda.

This may or may not work for you. Game plans, influencing tactics and personal styles are personal. But we do need as a profession to get more sophisticated.