Why I’m not pessimistic about councils’ response to vaping in the workplace

This past week has seen a continuation of different aspects of the debate about e cigarettes.  Neal Roff’s helpful and thoughtful blog for people new to using e cigarettes http://stormchildsblog.blogspot.co.uk/ was published.  And the equally helpful UKCTAS report on a depressingly “bad science” World Health Organization position statement was published http://ukctas.net/news/commentary-on-WHO-report-on-ENDS&ENNDS.html

But I want to turn to the report published over the last few days by  freedom to vape¸ http://www.tfa.net/freedom-to-vape/  a campaign of the Freedom Association http://www.tfa.net/about-us/

This report details the results of responses from local authorities to Freedom of Information Requests about vaping and smoking policies, sent earlier this summer.

“Councils ignoring PHE advice”

The report headline on their twitter feed says “87% of councils ignore Public Health England advice” on vaping being treated differently  You can read their comment posts and the report here http://www.freedomtovape.net/new_report_from_freedom_to_vape_87_per_cent_of_uk_councils_are_ignoring_advice_from_public_health_england?recruiter_id=107

Separately, another blog called vapers in power has published a blog linking to the “write to them” website encouraging people to write to local councillors about their policies https://vapersinpower.wordpress.com/2016/11/06/changing-how-your-council-sees-vaping/

Meanwhile, Simon Clark of FOREST has also written about this campaign on his blog http://taking-liberties.squarespace.com/ giving a different take.

Finally,  a report claiming – implausibly in my view and that of several lawyers I have spoken to – that councils are using “illegal” vaping bans was featured in The Mirror on 5th November http://www.mirror.co.uk/news/uk-news/illegal-vaping-bans-mean-third-9204911

Helping or hindering?

Transparency is always good, and indeed it’s helpful for citizens to write to their elected representatives giving their views on issues like this. I also note that the transparency of councils in Freedom of Information requests is far greater than the transparency of some agencies commenting on this, and the story is being used by some to bash councils and public health. I think that will prove counter-productive and some councils at least will decide not to tread on what feels like an increasingly fractious and flammable path, even if they can see good at the end of it.

One DPH recently told me anything they say positive is met by some people on social media – who really don’t represent vapers but many folk wouldn’t know that – with tweets about them being evil and how public health and tobacco control want shooting.  And then we wonder why public health folk are keeping their heads down in this debate.

The FTV report, while useful, doesn’t tell the whole story

There are several reasons why I don’t think the latest freedom to vape report tells the whole story. Doubtless some will disagree but let me list my reasons why:

  1.  The PHE report which contains guidance for workplaces https://www.gov.uk/government/news/vaping-in-public-places-advice-for-employers-and-organisations was only produced in July 2016.  The Freedom to Vape policy report was issued this past week. That’s just over three months between PHE guidance and the FOI report. The idea that most or even some councils will have considered, read and changed their policies on workplace vaping in that period is optimistic in the extreme, to put it mildly, given everything else they have on.  The Freedom to Vape report can’t be taken as more than a snapshot of what the position was at the time of the FOI. For many councils this will be in a queue of issues to deal with, and breaking even will be top of the list.
  2. How can I say that?  Because I know personally of a number of local authorities who are currently in discussion, or drafting revisions of policy and using, among other sources, the new PHE guidance and work from CIEH and others as a support. We are currently working on ours. I’ve commented on a few, and indeed many have commented on our draft policy.
  3. FOIs are an industry. Most local authorities employ a team to answer them. And I suspect (indeed having had informal discussions I know) that some councils have had their FOI team look at existing policy on the intranet and answer the FOI from freedom to vape. This won’t have captured that nuance. And it wont have captured those authorities where discussions have taken place but nothing is being written yet. The freedom to vape report, in that sense, misses out some work going on.
  4. You may say the FTV report will only miss a few local authorities doing positive policy development.  But local authorities tend to be pack animals. They watch and learn what others do and follow those they think are best, especially in an uncertain area.  And I know from speaking to people across the country that this is exactly what’s going on here. The few will shape the response of the many, in time. And three months is not enough for that to happen.
  5. It will take time, because there is no statutory duty on local authorities to do this, no policy obligation to do it either and the PHE guidance isn’t binding. Local authorities have discretion here and the key for people who are pro e-cigarettes is to help councils and support them use evidence and guidance sensibly and wisely. Frankly, the state of this debate will make some councils wish to exit the debate because it begins to look like a thankless low priority task when they’re about to fall off a financial cliff.
  6. Given everything else on the corporate agenda of councils (finances, social care, moving to business rate retention, devolution and so on) we need to find ways of making it easy for councils to do this. No amount of opprobrium and campaigning will make councils prioritise this if they think all they’re going to get is noise and hostility – even if it’s only from a few and the intention behind this report was about doing some good for peoples’ health.
  7. Several multinational tobacco manufactures have developed new, potentially risk reduced tobacco products which heat the tobacco but do not burn it. The Committee on Toxicology has been commissioned to evaluate the available evidence and at least some councils will probably  want to await this report before making any definitive statement or revision of policy.  Independent evidence on this latest development is extremely scarce but a study by the Dept of Public Health at the “La Sapienza” University of Rome suggests that it may be more appropriate to treat these products like e-cigarettes than to treat them like smoked tobacco.  What is likely is that councils, given everything else on their agenda, will not want to revise their policies several times within a year.

But there is a wider issue here, surely?  Why focus on just councils?  What about NHS, civil service, other public sector and commercial and NGO/third sector employers?  From what I can see and the discussions I’ve had with local employers, many of them don’t seem to have moved very far since July either. That’s because this shift will take time. The HR world is still in many places working out what it means in terms of employment law and local workplace policies and contractual entitlements.

Don’t just dismiss the FTV report

There will be some who dismiss the FTV report as a hostile publicity stunt, done in haste and poorly thought through. That would be a shame. And that’s a line I am neither going to believe nor support. The report was done by people passionate about the benefits of e cigarettes, I believe done for good intentions, and it does give us a snapshot of where councils are at and where the opportunity lies. The task now is supporting the HR community with getting on with this.

Time to re-orient how we debate with one another

I worry that there is a danger that some councils will see the report through the lens of some quite frankly hostile social media coverage (some from people who don’t like local government anyway) and decide they will wait and see what others do rather than trying to change things and get even more opprobrium.  To that extent, there is a real possibility that some of the social media coverage around this may backfire.

There is a whole discussion about people saying public health and tobacco control are fit for nothing, well I’ll address that another time.

Some factual corrections to the recent debate

There’s also some factual things to correct here:

  • Media reports that PHE advocates vaping rooms are not correct.
  • PHE has avoided prescriptive guidance and has proposed 5 criteria to help form local policies. The fact they have avoided prescriptive guidance means employers have to rely on their own interpretation of the law and their local contracts. The idea that most or even many employers will manage this between July and end of October is a triumph of hope over reality.
  • A conversation with a knowledgeable employment lawyer this morning told me that they and their legal colleagues have met with derision the media claim that local authorities are acting unlawfully on this. As someone who has worked in HR, I personally cannot see the legal claim for this. Employers remain able or not to consider whether or not to allow vaping.
  •  Establishing a right to vape in law will be very difficult, and would undoubtedly need legal precedent

Where next?

The adoption of the PHE principles will take time. We’ve been working locally on our policy for several months. That wasn’t reflected in our FOI response to this. This is not cause for anger or depression.  Nor is it cause for trading insults. We need to take the heat out of this debate.

There are lots of challenges lying ahead in developing and taking an evidence-based approach to welcoming e-cigarettes and similar devices. Setting to each others’ throats or “bigging up” an issue as a legal one when it isn’t – at least not in the way some folk report it – is not a recipe for elucidation.




HIV: leading and living beyond 90-90-90

Yesterday (Friday October 21st, 2016) a group of people convened to discuss the future of HIV services. National experts Prof Jane Anderson (National AIDS Trust, Homerton, ex PHE, now King’s Fund ) Dr Michael Brady (Medical Director, Terrence Higgins Trust and Clinician in South London) and David Buck (King’s Fund, leading the future of HIV services work) came and spoke. Their presentations, passion, vision (and from Michael Brady the mathematical modelling for an utter geek like me) were stunning.

Local experts (PHE epidemiologist, local HIV clinicians, vol sector services, social workers, commissioners and others) spoke. People with HIV were engaged (but really not enough, and not diverse enough,we recognise that.)

I opened the workshop with some slides on trying to understand where we are, what that means for commissioners, and where we might want to go. They’re here http://www.slideshare.net/jamesgmcmanus/future-of-hiv-services-hertfordshire .

I also wrote up some suggested conclusions at the end, and they are in the slides above. We’re still writing up the detailed work from people and we will share all slides and work online soon.

A strategic vacuum?

What national event was this?

It wasn’t. It was an event to try and navigate a local future for HIV services in our local area. It was held in what feels like a national policy leadership vacuum. At one point I almost put on an empty table the name cards for policymakers who seem utterly missing from this debate despite having being invited. NHS England were once again conspicuous by their absence from the table.

I thought a little while ago we didn’t need a new and another national HIV strategy. Well, I was wrong. We do. And it’s pressing.

Although the early years of HIV have gone, we still face challenges. Professor Jane Anderson pointed out that however good a thing it is in itself,  we risk seeing people who are maintaining viral load suppression as a success despite the fact that there are many other things going on for them, and for some folk a lot of work has to go into getting just that. 90-90-90

UNAIDS targets are, she says, a place within our grasp. But that isn’t enough.  I agree. That doesn’t mean we should just continue funding existing models of service either, by the way.

Back to the future?

In some respects we seem to have allowed our narrative on HIV go seriously awry. We talk about it as if it’s a manageable long term condition, with often very little nuance beyond that. And in some respects it may be. But the richness of narrative beneath and beyond that about what this means is needed. In and of itself this long term condition narrative is an impoverished one. It’s neither complex enough nor dynamic enough to articulate the similarities between and differences from HIV and other conditions like Diabetes or COPD.

Twenty two years ago I read a book called “Productive Living Strategies for People Living with HIV”. It changed my thinking at a time when we could only dream of what new generations of antivirals would bring, and the new health challenges which would come as a consequence of people living much longer were as yet unknown.

It’s time to survey the horizon, what we know, and go back to what we learned from those early years about what services need to be in place for what stages of living with HIV infection, and refresh this for our current situation.  We need a new narrative that providers and commissioners can coalesce around and one which takes us away from the simplistic “long term condition one.”

Dynamic condition, systems thinking

The long term condition narrative fails for me. When  I am faced with a friend who otherwise is holding down a job and is in terms of undectable load a success but needs a weekend of just collapsing in a heap and being cared for, or when I visit someone with multiple mobility and sensory problems which are transient and can’t get mainstream services to do what she needs, or when I visit someone whose anxiety and depression is partly caused by stigma, the long term condition narrative dissolves.

The dynamic nature of living with HIV and the fact that we need a variety of agencies doing different things, but probably one holding the ring, means we need a radical rethink using systems approaches.

I , for one, am excited about what the work of the King’s Fund on HIV futures will bring. Because expert people with and without HIV experience will look at the system and identify some local and national opportunities and barriers and feed into this. It’s long overdue. And the fact we got this bunch of folks to our local seminar was fantastic.

HIV in four voices

It seems we speak about HIV with at least four voices, none of them unified.

  • The voice of policy – seems focused on a one note monotone of treatment and testing and little else
  • The voice of experts – complex notes rising to a harmony which tells us we need a multitude of foci and a system wide approach to reduce transmission and secure quality of life
  • The professed voice of commissioners – has too often repeated the uncovincing melody that HIV is a manageable condition and not understood the nuance or complexity behind that, and seems increasingly out of tune with reality
  • The voice of people living with HIV – complex and not well heard yet vital

This discordance needs national and local leadership to once again sound in unison the state of HIV in England and the must dos which flow from this.

Renewal and re-engagement

We face some significant challenges, and we need to navigate a way through them. Some lessons from yesterday were:

  • HIV shows different epidemiological characteristics – no one strategy for testing,diagnosis and treatment will work everywhere in England
  • The treatment can cause as many problems as it solves
  • Official statistics even on testing uptake dont reflect all the work going on
  • People with HIV present needs beyond NHS testing and monitoring and these vary by stage of disease and by person
  • The unity of the person – physical, emotional, psychological, spiritual – has gotten lost in the discourse about getting folk to an undetectable viral load. That’s brilliant, but the melody of thriving, coping and surviving with HIV is more complex and we must recapture that
  • No single national one size fits all strategy is sensible, but there are some things which we need national leadership for – not least a push towards integration
  • You can read HIV into the principles of the NHS Five Year Forward View. Where is the leadership?
  • Can anyone point me to a single Sustainability and Transformation Plan which addresses this?
  • We need to still do more to engage people with HIV in service design
  • We need to refresh and renew self management
  • We need to ensure services join up
  • We need a clear comprehensive system wide view from preventing transmission to diagnosis, treatment and care and self care
  • The complexity of HIV as a consequence of all of this is often not well understood by commissioners

We need to articulate the new system from PrEP to Care and back.  On 6th December I have been invited to speak to the National HIV Providers’ Forum on something like this, as a commissioner.  I will probably learn and take much more than I contribute, but this is a discussion we need to have together.

Jane Anderson brought to life the complexity of HIV with three vignettes of three people who, while all virological successes in 90-90-90 terms, are complex and need more. Stories from people in the room of treatment need and experience ranged from those thriving with HIV who need their testing and monitoring to fit round their lives to those with a range of complications and issues who found existing services dont meet their needs.

Public sector finances

There is less money. Commissioners in a number of areas are cutting HIV services. What we should be doing is sitting down and doing re-visioning exercises to look at what is needed and for what cohort of people.

It is simplistic and untrue to say HIV is easily managed by all. Equally it is simplistic and untrue to say that the service models of fifteen years ago (lunch clubs) are what we need now.

We need a different dialogue on charting a course for services.  I attempted to do some of this in my population segmentation slides.

That doesn’t mean financial cuts won’t come. But it should mean that redesign, prioritisation and service integration become more important and fairer. This will continue to have profound implications for providers and commissioners. Jane Anderson suggested that some providers in HIV could branch out to other areas too. Rather than integrate HIV with other generic services, the stuff HIV services have learned needs to be shared with others. I can think of areas like Diabetes, COPD and Heart Failure where the expertise and know how in HIV could be easily transferred to the benefit of many. (My dad had COPD heart failure. Some of the most successful stuff I did with him I learned from friends I cared for years ago.)

All the more reason why we need all the system leaders to sit down around one table together and share one public pound. The taxpayer has a right to that, and so do people with HIV. NHS England, are you listening?  We know you have an impossible task with diminishing staff but we could help you out of this…there are ways.  Come, let’s sit down and talk about how we help each other.

So what next?

At the end of our workshop we had a range of actions. In short, we’re having a redesign to create a new strategic plan and we are going to try some new ways of engaging people with HIV in this. But several people said it’s about time to go beyond UNAIDS 90-90-90 targets.There were various ways of expressing this, but for now here is my (perhaps rather inadequate) take on this below. UNAIDS 90-90-90 tells part of the story, but everyone felt it wasn’t enough. And together we articulated some more tasks.

Beyond UNAIDS 90-90-90

UNAIDS 90-90-90

90% of people diagnosed

90% of people on treatment

90% of people achieving viral suppression

OUR ADDED 90-90-90

90% of people engaged in shaping and designing services

90% of people with optimal quality of life

90% of people aware of the facts on HIV and commited to reducing stigma

Light amidst the encircling gloom

Ambitious?  You’re dead right. Achievable? Yes, as a marathon not a sprint. Necessary? I believe so. If we take everything we should believe about HIV – we want an end to HIV ongoing transmission and it’s doable, HIV is manageable, it’s complex, it changes and stigma are huge issues – then these priorities naturally fall out of any decent strategy.

But we need national leadership in this, and that needs to be joined up across all national agencies, not just left to one, while others pick and choose whether to ignore or engage.

Who’s up for it?



PrEP for HIV: great, but watch what happens next…

So we have judgement over who in England has the responsibility to fund pre-exposure prophylaxis for HIV, or PrEP. https://www.judiciary.gov.uk/judgments/national-aids-trust-v-nhs-england/

Mr Justice Green has declared in favour of the National AIDS Trust and Local Government Association. NHS England has misdirected itself as to its statutory powers and duties on PrEP, and can – indeed should – see itself as the responsible commissioner.  There are reports that NHS England will now appeal.

The judgment says quite clearly that

“Notwithstanding any and all of the above the issue for the Court is a narrow one – is NHS England correct in its analysis of its powers and duties? If it is then the wider policy and budgetary issues which arise are for the Secretary of State and Parliament to sort out.”

His judgment goes on to say at paragraph 6:

“In my judgment the answer to this conundrum is that NHS England has erred in deciding that it has no power or duty to commission the preventative drugs in issue. In my judgment it has a broad preventative role (including in relation to HIV) and commensurate powers and duties. But I have also considered the position if I am wrong in this. On this alternative hypothesis I am of the view that NHS England has still erred in concluding that it has no power to commission the PrEP drugs in question. Either: (i) it has mischaracterised the PrEP treatment as preventative when in law it is capable of amounting to treatment for a person with infection or (ii), NHS England has in any event the power under the legislation to commission preventative treatments (and therefore falls within its powers however that power is defined); because it facilitates and/or is conducive and/or incidental to the discharge of its broader statutory functions.”

This is quite  significant judgment. I will be interested to see what the grounds of appeal are.

NHS England will now, if it doesn’t appeal or if it loses the appeal, have to consider PrEP for commissioning on its own merits. It isn’t, contrary to NHS England’s lately arrived at view, a duty for local authorities. Meantime if NHS England appeals we are still in limbo.

This judgment is worth studying in detail, not least because of what it says about NHS England’s powers. Paragraph 110 says

“First, the power of NHS England includes commissioning for preventative purposes and this includes for HIV related drugs. Second, in the alternative even if NHS England does not have a power to commission on a preventative basis the commissioning of PrEP is to be treated in the same way as the commissioning of PEP, i.e. both are provided on the basis that the patient is assumed to be infected. Third, in the further alternative the commissioning of PrEP is within the power of NHS England under Section 2 NHSA 2006, even if properly analysed it is a preventative treatment.”

This judgment as it stands emphasizes NHS England’s role as part of a preventive system. That’s an extremely welcome judgment for the health of the public. Whether NHS England agrees, is another matter.

The decision is important for other reasons too, because of some of the principles it reinforces is about what NHS England can do, should it wish, and how it shouldn’t take a narrow and restrictive view of its powers. I predict others will study this as part of the process of challenging NHS England decisions in future. The equality argument advanced was never going to be even the main argument of weight here, never mind the clincher. The judgement makes this clear. This was about powers and duties in the provision of a health service, and whether NHS England has them on PrEP. And the judge makes clear NHS England does. I’m not surprised NHS England are talking of appealing. The ratio of the decision is uncomfortable reading for any organization wanting to take a narrow interpretation of its powers and duties in the current financial climate. And this judgment drives right through that.

NHS England would have had us believe it’s own version of two ridiculous things before breakfast: that it had the power to fund and run a team giving healthy town planning advice to local authorities as prevention which is clearly a local authority function in law, but didn’t have the power to commission HIV treatment as prevention because that was, err…a local authority function in law.

That bizarre and unhappy rationale was forensically pulled apart and found wanting in a judgement which spans over 60 pages.

The same taxpayer meanwhile foots the bill for one part of a system (NHS England)attempting to shunt costs onto a second (local authorities) which that second part of the system rightly resisted, only to have a further part of the system (the High Court) quash it. Tax pounds went into legal fees, not HIV prevention or treatment. Meanwhile the human cost is that some people who might otherwise have remained HIV negative may have become HIV positive, at least some of whom those tax pounds could have kept uninfected.

It’s time now for NHS England to sit down and have the discussion about a proper strategy to end HIV, and get us to the UNAIDS 90 – 90 – 90 targets. It can be done. It ought to be done. And NHS England needs to be at the table as a welcome partner, not a grudging paymaster.  England needs a proper HIV strategy, and an end to this unedifying shirking of responsibility.

The upside for NHS England is that if it does this properly it will gain financially from reduced costs for HIV anti-retroviral treatment for those whose infections are avoided, and from the costs for related ill-health and complications. It will also gain £520million by some estimates from the money it will save on switching to generics.

I put my hand in my own pocket to contribute to the National AIDS Trust’s costs. I’d do it again with no hesitation.  But just like you I’ve also paid through my taxes for NHS England’s intransigence and bad grace. I’ve also paid like you through my taxes for local authorities to take their side of the matter to court.

Don’t get me wrong. I am very, very, grateful for this decision.  Not just because it establishes NHS England does indeed have the power to commission anti-retrovirals as it kept saying in all its documentation until its Damascene u-turn earlier this year. But also because it should give NHS England pause for thought before it tries this with something else it doesn’t want to fund. And NHS England seems to have acquired an appetite for cost shunting.

NHS England asked us to believe for over eighteen months that on the face of it, it wanted to be the commissioner, said it was the commissioner and then in March this year had a blinding flash of realisation that it had no powers. The judge has clearly traduced that clunky and wholly unsatisfactory story.

We have, as a system, some big issues to be discussed now and NHS England needs to come to the table as a partner. On the agenda we need to consider:

  1. Will NHS England fairly prioritise this through the commissioning process, or will we get further tactics and cost-shunting attempts in an attempt to avoid commissioning PrEP?
  2. What happens to the participants on the PROUD study, which announced the closure of access to PrEP on 29th July? http://www.proud.mrc.ac.uk/
  3. Similarly what will happen with acces to PrEP through the forthcoming DISCOVER study?
  4. What happens now to the £2m NHS England funding for early implementer sites? https://www.england.nhs.uk/2016/05/prep-provision/
  5. Who pays for the associated testing (kidney function etc) for people on PrEP?
  6. How do we roll it out for those most at need?
  7. How will we get a proper Treatment as Prevention strategy with a partner – NHS England – that seems difficult to communicate with and is struggling with so many challenges?

But all these things notwithstanding, there are two other things foremost in my mind. First, that this at the end of the day has been about money. Second, that we are not out of the woods yet, we will need to watch very carefully to ensure that NHS England puts the issue of PrEP fairly and reasonably through its commissioning process.

Why do I say this?

First, the money. Those more cynical than I might conclude this story is and always has been about money and the fact NHS is struggling to contain a burgeoning set of demands for specialised commissioning, and the use of statutory responsibilities as a flag of convenience. There is no doubt NHS England faces tough financial challenges, with the Treasury watching very closely and the Public Accounts Committee recently saying NHS England hasnt communicated clearly how its specialised commissioning function fits with the future strategy of the NHS or its need to save £22billion. http://www.nationalhealthexecutive.com/Health-Care-News/nhs-england-told-to-set-out-how-specialised-care-fits-within-fyfv-and-deficit-by-october

NHS England is heading to overspend its specialist commissioning budget, at a time when the pressure is on. You can read more here. http://www.hsj.co.uk/topics/finance-and-efficiency/nhs-england-forecasting-first-ever-overspend/7009560.article . NHS England is clearly  struggling to control the costs of specialised commissioning http://www.nhsconfed.org/resources/2016/05/national-audit-office-critical-of-specialised-commissioning and avoiding bills for PrEP would have helped, even a little. They do face an extremely difficult task.

Second, we need to make sure that the future decision making process on PrEP is conducted rigorously, equitably, and based on its merits. one of the reasons advanced by NHS England for not taking PrEP to its specialised commissioing process was the argument that other providers and manufacturers of drugs and technologies might legally challenge. I wonder whether further, similarly creative and equally implausible , arguments will be adduced during any appeal or the next stages of considering PrEP. NHS England has made it repeatedly clear that it does not want to commission PrEP.  It even blamed – in what some have suggested is a tactical move to remove sympathy from the PrEP lobby – the delay in commissioning eighteen other procedures, including specialised procedures for children, on the PrEP judicial review, https://www.lgcplus.com/services/health-and-care/nhs-england-blames-hiv-legal-action-for-new-treatments-delay/7008311.fullarticle .

None of this, however, excuses the process we have just been through. What it does mean is that we must keep a very close eye on what happens next. We need to be scrutinising every paper on PrEP from NHS England very, very carefully.

Public Health after the Brexit vote: keep calm and carry on

Well, today we had the EU referendum result.  And whether you are happy with it, or not, you will doubtless have seen significant speculation and some forecasting about what it may or may not mean for public services.

Speculation abounds about the next steps. The vote to leave doesn’t exactly give a thumping mandate for leave, some say. Others are jubilant. Yet others suggest that Parliament, which still has to vote to invoke Article 50, may decide not to. A last minute deal may be found, some suggest. Nearly three million people have already  signed an online petition for a second referendum, and I will be out of date on that within minutes

All of this speculation feels overlaid by a mix of shock for many, elation for some and grief for others at a decision we have not yet as a nation fully understood the implications of, whether you were in, out or don’t know.  It feels a bit scary, both for Brexiteers and EU-romancers. I may well personally wish we had voted to remain, but the task now is to keep going, and adjust our strategy for the health of our population to the developing circumstances.

Whether you like the outcome of the vote or not, our job is clear: pull together, articulate what we need to do to make this work as best we can and make sure we are neither distracted by rumours nor dragged into needless scares. Recession is not inevitable. As ever, this will be complex and nuanced. Time to keep calm and carry on.

There will be a strong psychological dimension to this change – not just in relations between families, partners, friends and work colleagues who took different sides. The  nature of what it means to define ourselves as British or European will change, especially if the Union itself moves further towards independence for Scotland; and sovereignty changes in Northern Ireland as yet unkown. The facebook page for Britain will continue to say “it’s complicated” for some months, it seems.

Navigating forward will take leadership. Speaking to a few colleagues today, we are all wondering what the next steps for us are, and what public health leaders should seek to do. I think there are several tasks for public health leaders to be getting on with, to enact what the public have said they want. So here’s my attempts to put them into blocks.

Short Term (2016)

Let’s be honest, nobody really knows what will come out of the woodwork this year. There is no blueprint for this. We may see a reshuffle at Cabinet level. We may see a period of political instability. We will see a new Prime Minister. We will see a continued emphasis on reducing the defecit and the cuts will not reduce. Even if the economy picks up considersbly, I have alteady blogged peviously on hee about how government has chosen to shrink the public sector as a deliberate policy choice, and not just for economic reasons.  Will that reverse? Highly unlikely in the short term. We are not going to magically see hundreds of millions immediately reinvested into public services including the NHS because it will take two years at least to disentangle the web of finances from Europe.

In any case, signifiant proportions of the money we send to Europe already come back for investment. The Financial Times yesterday pointed out that those areas most heavily for leave were most economically dependent on the EU. Will that money be replaced from the UK’s eventually retained funds? We dont know. What will be the health impacts of that money not being available in whole or part? Could it be better spent? What happens to EU funded projects to get people into work? What about EU funded health research for innovation?  All of these are issues we will have to watch carefully.

And we just cant put ever more money into the NHS. We have to  face that fact. There are some major structural challenges to NHS estate, finance, organisation and ways of working which need a range of solutions. Brexit in and of itself will not answer all of those. It may bring some benefits, it may not.

We will almost certainly have a jumpy few months where scare stories in the media or from various sources will distract us, and then as things begin to become clearer we will doubtless settle down a bit. People we encounter at work – for or against exit -and in our personal lives will be curious, scared, worried, hurt or angry in different measures. We have a leadership task to keep our teams and our partnerships on track and sighted on the big challenges ahead.

  • In the short term, we need to keep running the system, calmly and determinedly. We are in the middle of significant cuts imposed by government and making sure services run is the most important thing. Very little is likely to change hugely in terms of the law before Autumn.
  • Our workforce may need reassurance. People will be wondering what this means, if anything. Non UK Nationals who work for us may wonder if they’re still welcome (I’ve been asked that already.) Well, they are still legally entitled to work where they work unless and until the law changes, and an important task is to reassure them they are still wanted and important, whether they work directly for our agencies or providers.
  • Some things we have been waiting on like the Obesity Strategy and Drugs Strategy may get kicked further into the long grass as government focuses on understandably more pressing matters
  • Procurement rules and regulations will still apply unless and until government changes them. Our biggest leadership task right now is making things work and reassuring folk they will.
  • All other sets of laws derived from Europe will continue to apply unless and until they are abrogated.
  • There will be no economic miracle which will see masses of money redirected into the NHS or Public Health. There will be a need for building a strong market economy for Britain.
  • We still have Sustainability and Transformation Plans to deliver with the NHS, and prevention is needed more than ever to reduce the burden of ill-health.
  • The NHS financial crisis is still with us, and the massive cuts in local government too. In the short term, that will certainly not change.

Am I sounding blunt?  Well, there are two other really important things we must be keeping our eyes on at this time, too:

  •  We have no idea whether the market upheavals will mean a recession and the need to either raise taxes or make more cuts in public spending. There seems, on the face of it, no reason why a recession must happen. After all, Germany alone exports 50 billion euros worth of goods a year to us.  The UK remains an important market economy. But markets, and people in them, can be perverse. We have a job to do to counter anyone who would simply talk us into recession when that needn’t happen. Whatever our views, now is the time to focus on keeping a strong economy.
  • Devolution discussions and plans may go into difficulty or delay as people wonder what the new context means. They dont need to, necessarily.

Medium Term (2016-18)

Public Health Leaders are going to have to be able to scan and span both the detail and the horizon for well beyond next two years at least.

The horizon scanning involves things like whether a recession is coming, where we and the NHS and Social Care get workforces for essential jobs from and things like whether during the changes population health gets better, stays the same, or worsens. Resricting UK jobs to UK citizens looks simply impossible in the short term given the amount of money we’d need to invest in training alone.

  • Those of us reliant on EU and extra-EU workforces to run services will need to think carefully about workforce planning, and start that thinking soon. What will government do, if anything, about non-nationals here? What about recognition, job supply, recruitment and retention?  How do we build our workforce and where do we get it from?
  • The speculation that diversity law will change massively seems to me to be scaremongering. The Disability Discrimination Act is an important UK Act, for example. That doesnt get abrogated because we leave. I cant imagine any government will simply take an axe to every EU inspired UK law. For one thing, people on all sides of the debate have said some of these laws are good – disability discrimination, for example.
  • Some EU health measures such as air quality will need to be considered – do we adopt them in UK law or not?
  • Those areas heavily benefiting from EU funding will need to consider the impact on health outcomes from what may happen to that funding. Will it simply be replaced from inside the UK or will it go into making the budget balance, effectively bringing further cuts in public spending and infrastructure, and with it population health issues from employment to economic performance to access to services?
  • Population mental health, self-harm, suicides, harmful alcohol consumption and a host of other things historically rise or fluctuate in times of national uncertainty. This is a current time of uncertainty. Monitoring this is going to be crucial.
  • Trends in employment and economic activity will impact on health. We know that. What way will this take us?
  • What are the health impacts of the changes in funding, law and governance?

The detail will include looking at whether, if we do go ahead, the process of leaving necessarily abrogates EU laws like the working time directive,and what, if anything, replaces them. Understanding this is crucial if we want to make sure that some of the avoidable cracks, missing points and dysfunctions arising from things not thought through in the 2012 health and care reorganisation don’t get repeated.

There will remain, despite exit, the need for public health and scientific collaboration across Europe. Health protection, disease surveillance, scientific collaboration on research and treatment and response to some common threats (pandemics, emerging infections, antimicrobial resistance and ‘flu) will continue to be important simply for reasons of economic migration flows (which won’t cease anytime soon), trade and tourism travel, geography, climate and 30 years of doing these things together. We’ll still be in NATO, WHO and other collaborations unless we decide to leave, and so Scientific leadership is going to be crucial to articulate what a new science collaboration framework looks like. And PHE will still work collaboratively with others to protect our health, including european nations. Monitoring health outcomes across the EU is likely to change. Losing skills and brainpower needlessly as bright and commited non UK academics, policy professionals, clinicians and providers move away is, at the stage, avoidable.

Longer Term (2018-2022)

Leaving the EU won’t necessarily abrogate the Human Rights regime or indeed existing related precedent in law (judge-made case law by European courts) unless and until government says so. So a lot of things will need time to change, unravel, be abrogated or simply absorbed. Expect policy confusion and complexity as we go on this journey. Its just part and parcel of such huge change.  A big question is whether we have the calibre of political and civil servant leadership at national level to do this strongly and coherently, and how that is replicated at local level.

Monitoring health outcomes and the economy and looking to see what kind of public services will be around in 2022 is going to be the most important task. Will the consequences of exiting the EU make us more or less prosperous?  What will the workforce look like?  What will be the picture of inequalities in health?  Will our public services be financially sustainable?

I don’t have answers to these, and I’m not sure I would trust anyone who claimed they did right now. As yet we see through a glass, darkly.  But one thing I am convinced of: more than ever this is the time to make prevention of need for costly services work.  More than ever this is the time to get people as fit and healthy – mentally and physically – as possible. More than ever this is the time to look at the big challlenges to an equitably healthy population.

These things remain…

Some things won’t change – the need to have a strong economy is crucial to good health, and a healthy population is crucial to a strong economy: our workforce can’t compete with China if it can’t get off the sofa. And our workforce needs to be emotionally and psychologically strong and resilient. Some economists suggest Brexit will make this better, not worse as others fear. Brexit doesn’t change that economic challenge- keeping the economy going. It may or may not make it more complex. It may or may not make it better. But building positive psychosocial working environments is going to be crucial to Britain’s economy, whatever shape our governance and sovereignty will take. Equally, ensuring schools and other public services improve and protect the health of the population will never have been more important.

All of this requires some British sangue froid, as they don’t say on the European mainland.

We have work to do. Even if all around us is flux, we can and should articulate the public health contribution to where and what Britain will be , and the risks and benefits we see in policy choices. As I said above, I may well personally wish we had voted to remain, but the task now is to keep going, and adjust our strategy to the developing circumstances, for the service and the good of our citizens.

Bon chance, mes amis, as they say in Scotland.

Unrealistic, unaccountable, unacceptable: NHS England and #PrEP

I write this in a personal capacity and don’t claim endorsement of any organisation for my views.

Within the last week we had an inspiring letter in The Times (May 30,2016) signed by 30+ HIV agencies in the UK  who reminded us that we could end HIV.

The news reached us today that NHS England will not fund PrEP (pre exposure prophylaxis) for HIV, driving a coach and horses through one important strand of that ambition.  https://www.england.nhs.uk/2016/05/prep-provision/  Their legal advice is also available on that link.  The relevant committee paper is here https://t.co/z0wCcZdW6b

The BBC coverage here is also worth a read http://www.bbc.co.uk/news/health-36421124

NHS England says it took the decision based on external legal advice which said local authorities were responsible for prevention, which means they cannot legally provide it. Their legal advice reads in some sections word for word like the rationale they originally issued in March for not funding it. How very covenient. How very consistent. And how wrong-headed.

I think today’s decision is unrealistic, unaccountable and unacceptable. True, PrEP might not get through a proper rigorous prioritisation process when seen against some other competing priorities. But at least NHS England could put it through one rather than the disappointing exercise with a pre-assumed conclusion staring at us from the report, which we have just witnessed. Isnt’t that why we have a prioritisation process?  So reasonable decisions can be made in a reasonable way? (A central pillar of our public law.) The process here seems unreasonable and unaccountable.

I wrote at the time of the original decision in March 2016, in local government chronicle, that this decision didnt make sense in and of itself. I suggested it was a not very transparent way of shunting prevention costs onto local authorities http://www.lgcplus.com/services/health-and-care/jim-mcmanus-the-nhs-has-shunted-hiv-costs-on-to-councils/7003557.articl  It seems to me this is about funding and finance, with the veneer of legal restriction to add the barest credibility.

I also suggested in that article that this decision, I am sure, will be being seen internally in NHS England against the background of an enduring and worsening NHS financial picture.

By most accounts the Treasury and Department of are Health trying to grab fiscal control of an organisation which has not only had extra injections of cash but has been allowed to exceed its treasury agreed departmental expenditure limit. Only this week we note that the NHS system planning guidance says NHS provider trusts need to break even, and in almost the same moment the Chief Executive of NHS Improvement, the regulator, admitted he expected a further NHS provider deficit in 2016-17.

We cannot divorce the burgeoning financial pressure on the NHS specialised commissioning budgets from what NHS England is presenting as a rational, considered decision on PrEP and its commissioning responsibilities, whatever their legal advice says. Somebody prove me wrong. And I believe the legal advice to be mistaken.

I think the PrEP decision is wrong for a number of reasons:

First, the economic and prevention case for PrEP is made, here is just one reading of it, http://www.nat.org.uk/media/Files/Policy/2016/Why_is_PrEP_needed.pdf , and  it is made well enough to allow investment not only in other countries but in England too.  Today’s decision feels like short-sighted disinvestment, not a coherent decision based on a thought-through strategy to end HIV and save both lives and cost to the public purse. It is disinvesting now to reap further avoidable cost, disease, disability and misery later. On any view that’s a poor strategic move.

Second, on the face of it, the argument that local authorities are responsible for prevention seems to me to be an arbitrary flag of convenience which is unrealistic, unreasonable and contrary to existing NHS England practice. There is a massive difference between not having a legal duty to do something, and assuming that duty stops you using any general powers you have to do something.  This doesn’t stack up.  I am happy to stand corrected but my reading of NHS England’s own advice, documents and practice leads me to these conclusions. But let me explain why I conclude this:

  1. Are we really to believe that NHS England spent eighteen months agreeing in their own documents that they were the responsible commissioner for PrEP and antiretrovirals generally, only recently to have legal advice to the contrary? And what are we to make of the fact this advice coincides – with scarily serendipitous timing – with the massive financial crisis in the NHS and the specialised commissioning budget?  It seems to beggar belief that they proceeded on the basis they were responsible since their foundation without taking legal advice that told them this. Or were those who suddenly achieved this surprising volte face somehow not cogniscant of their responsibilities for the past eighteen months?  Are they really constrained in law from acting now to save money later on?  On any public policy view about the good of the NHS this is an entirely flimsy and unconvincing argument.
  2. The legal advice, and with it the argument that local authorities and not NHS England are responsible for prevention, seem to me to be undermined by the prevention focus in the NHS Five Year Forward View.  https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf Are we really to believe that some types of prevention (diabetes) are in scope for NHS England while others that will save like for like as much or even more money for the NHS than diabetes and heart attack reduction are out of scope because of one regulation?
  3. Today’s position on the face of it seems also to be undermined by the NHS Healthy New Towns initiative.This is a long term (think twenty years of more) prevention initiative which, err, works on helping local authorities plan new towns which prevent illness. Hang on, I hear you say, Local authorities are responsible for prevention and NHS England isn’t, right?  Well NHS England seem to be telling us they’re not responsibile for prevention, unless they decide they are and it’s much cheaper than PrEP.  The NHS England information on Healthy New Towns is here.  https://www.england.nhs.uk/ourwork/innovation/healthy-new-towns/  This is a much vaunted initiative by NHS England. Simon Stevens himself has claimed the idea as his own and as part of the advance of a prevention focused NHS. https://www.england.nhs.uk/2016/03/hlthy-new-towns/    Now, I may be being picky, but Town Planning definitely is a local authority not an NHS England responsibility. Believe me, I am sad enough to have read both planning law and planning guidance and NHS England’s job this is not.  But, despite it not being their responsibility, a team of staff are employed, a programme board exists, a bunch of local authorities have bid to be NHS Healthy New Towns and they will receive free consulstancy and support (no cash) all at NHS expense.  Don’t get me wrong, I think this is a good idea,  done on the cheap and NHS England are the wrong people to be leading it, but nonetheless a good idea.  My point is that if this can be justified in legal and policy terms by NHS England (when the economic analysis is, to say the least, aspirational and) when it is clearly the statutory responsibility of local authorities; the conceit that PrEP – which will save the NHS directly millions of pounds – is not, leads me to feel the system seems to have collectively taken leave of its senses. Why wouldnt you prdently act now to save money later?
  4. There is a strong rationale in the NHS Five Year Forward View on a “radical upgrade to prevention”. It mentions significant health issues causing cost to the NHS.  If a lifetime cost of HIV treatment – to the NHS – is easily £360,000 then how does the prevention of HIV cost to the NHS not stack up alongside Diabetes as a ready and achievable win?  Apparently “the radical upgrade” has hit a need for debugging.
  5. The NHS ENgland legal argument conveniently seems to forget both the incidental powers of the NHS and their ability to do things reasonably related to their core business. If they have no incidential powers, then where on earth did NHS Healthy New Towns come from ?  If they have no incidental powers, then how is NHS HEalthy New Towns not ultra vires and why aren’t we all complaining to the Public Accounts Select Committee and the National Audit Office that NHS spend on Healthy Towns is ultra vires and unlawful. Again, this seems inconsistent.
  6. The argument that others could challenge any NHS England  on PrEP also seems an entirely cobbled together port of convenience. Does this mean that PrEP manufacturers can now start challenging cancer drugs, or cancer manufacturers specialist mental health commissioning? If we start going down that path we will arrive at unpicking the whole basis behind any NHS prioritisation process. Was I lucky that when I was being treated for a grade IVB cancer the drugs I was given were not challenged by another manufacturer and hence I am still alive? Or is this hiding behind a possibility that – even if it were legally correct – is highly unlikely. And behind this hiding constructed rationale that others can challenge, there remains the fact that in any case NHS England could mount a strong public policy and fair process defence against in the light of challenge. Well, they could have if they had actually applied a process which felt anything other than disappointing and pre-concluded.

Third, we need an NHS which more than ever, for moral, humanitarian, policy and economic reasons, is focused on Prevention much more than it ever has been. Unfortunately that isn’t what we got today. And the idea behind it, that a set of regulations presents the NHS commissioning treatment as prevention when it seems to take a very different set of rules to what other prevention work it undertakes (NHS Healthy New Towns) seems flimsy, hastily conceived and incoherent.

But there are several much more important issues at stake here:

  1. We have the UNAIDS 90-90-90 initiative http://www.aidsmap.com/90-90-90 and a number of other opportunities including Treatment as Prevention to potentially end HIV.  Other countries are moving closer.  Treatment as prevention must inclide PrEP and PEP as well as other strategies.
  2. We need, more than ever, prevention to work for us. Derek Wanless in 2000 predicted that we would get to a point where we would be swamped by preventable illness of all kinds. It seems we’re already where Wanless predicted we would be if we didn’t do prevention well. I wrote in December last year about a proper coherent narrative and plan for Prevention.http://www.lgcplus.com/services/health-and-care/the-government-must-do-more-than-talk-about-prevention-in-healthcare/7001110.article  We’re still not there, the NHS Five Year Forward View isn’t that coherent narrative by itself and we have much work to do.  We need to get a grip on the spiralling cost of health care. Prevention needs to be embedded across the whole system. On any view which was even vaguely informed by economics PrEP would make sense.

Finally, a key policy aim, explicitly stated by Government, NHS and local authorities is the integration of health and social care, and prevention. This is a major policy agenda.  That means everyone has to take seriously how we prevent avoidable death, disease and disability. In what world could ending new HIV infections not feature among many other things as important, seen against this policy priority?  As Inside Outcomes (@InsideOutcomes on twitter, http://www.insideoutcomes.co.uk) tweeted this evening “A demarcation between prevention being Local Authority whilst the NHS is purely reactive seems contrary to any sense of decent integration.” Well put.

What great dangers we are in by these unhappy positions. And what entirely preventable ones. Whither the radical upgrade?



Self Care, Resilience and Self-Emptying: thoughts

There’s so much I could blog about at the minute, but there has been little time.  I want to blog about the debate polarisation going on in diet and tobacco harm reduction and whether this polarisation helps the people we are supposed to be serving (remember them?)  Another time.

But a few things have led me to blog about self-care and self-emptying.  It’s year of volunteering from today, and I’m offering some resilience and self-care sessions to volunteers and leaders as part of the year. I’ve been doing this for some time now.

I am, outside work, someone who volunteers. From cleaning the church I am part of to being a Trustee on several charities to being an advisor of others.  I love it. It usually energises me. There are times when it doesn’t (10pm in a finance committee and we still can’t agree on whether health and safety allows us to replace our own ceiling lights), but they are rare.

My interest in public mental health

I never really thought of myself as having that much more interest or much of a role in things to improve the mental health and resilience of our population than anybody else.  And I look back and realise that this was not really doing what I could have done. One of the people who changed that was Executive Member for Public Health. She has a passion for good mental health that you can almost touch. And it’s energising. And the past three years of reflection and action spurred on by her prompting have suggested to me a number of different dimensions of the mental health of our population that I have often not thought through until more recently.

Similar challenges, different situations

In the last two months, looking through this public mental health lens, some similar issues have been thrown up by five different groups for whom I’ve delivered some sessions:

  1. A group of social and health care workers (clinicians,managers and volunteers) who all want to understand their faith and their work integration better. Part of the answer for at least three of them was a manager hostile to their faith or insensitive about their disability. So much for workplace diversity!
  2. A group of volunteer leaders who wanted a session on leadership in public health volunteering
  3. A group of people who have survived the mental health care system and want to lead a public mental health agenda
  4. A really good conference for the International Day against Homophobia on May 17th where statutory agencies and lgbt advocates came together, and I was a speaker
  5. Some people preparing to work out what their role for health improvement is in the Hertfordshire Year of Volunteering, which kicks off today

The issues are essentially about self-care and resilience. They all struggle with it. We ended up in every session spending some of the time I had alloted to talking about it. Usually because stuff in the group brought it to the surface more or less tangibly.

Self-emptying : the good and the bad

A major commonality is they all demonstrate what I call “kenotic”styles of leadership – from the Greek kenosis – for self-emptying.

Kenosis for me given my upbringing is a very, very, VERY Christian concept because it’s what Jesus did – emptied himself out of love for the sake of others – and it’s what so many of my heroes did and still do, whether of any faith or none.  It’s striking how many people – possibly quite unconsciously – engage in this kenotic style. They give and often do not count the cost, because that is what they feel will help their fellow humans. Self-emptying leadership and service (and whether you’re cleaning a floor or delivering training or writing policy you’re leading) is it seems so very common among us all.

There are great benefits to self-emptying leadership. It gets things done. And it can actually be energizing, but only if you have something else replenishing you. From Jonny Benjamin, who – with great benefit for us – didn’t end his own life and started doing enormous good on mental health to the mother bereaved by suicide, aching still from it, who creates the safe space for others to ache and hurt, these kenotic leaders soothe and change and charge the world with their love and concern.

But there are risks and downsides. I speak from first-hand experience. Stress, burnout, not coping. Kenosis can also mean avoiding the fundamental issue at heart (the times when someone tells me “I havent grieved” or “I dont really accept myself”), that well practiced ability to love others into a better place while being unable really to love oneself. And boundaries can go awry, leading from service to abuse of power.

A public mental health issue

Why am I writing about this?  Because it is fundamentally an issue of population mental health. Scientific research (such as there is) on volunteering will tell you it brings benefits but has costs. It can energise and it can burn out.

In a society which owes so much to volunteers, or people in their day jobs who go above and beyond the call of duty, and especially in a year of volunteering, we need to look seriously at some of the issues here. It is a public mental health issue: building resilience rather than building in risk and vulnerability should be a key concern for us.

How do organisations support the kenotic leaders?

I asked the question especially about how employers support those employees who are really “out there” in their leadership changing things. I can think of a muslim colleague, a vaping advocate colleague and a transgender equality advocate colleague who have all taken personal, reputational and other knocks and risks for what they believe is right. How is their organisation supporting them?

So, what do we do about it?

Kenosis is not the only style of service, but for those who get the balance right between self-empyting and being replenished, the rewards outweigh the risks and things progress. For those who dont, stress, burnout, exhaustion and illness can become the order of the day.  So the first thing NOT to do is try to stop it.

I find myself talking again and again these days about how a fundamental part of being resilient in a busy life is to have a self-care strategy: tools or tactics to make sure that you can and do cope and thrive.

I have spent the last eight years doing self-care as part of leadership training.  from future public health consultants to young sisters and brothers in religious life who have just taken their first vows and are thrown in the deep end of service to volunteer trauma counsellors to LGBT or mental health advocates.

There are several pillars to self-care:

  1. Learn to appraise sources of stress and whether they are really stressors (things you dont have the resources to cope with) or whether they can be made neutral or even positive. (Sometimes a deadline is energizing, especially if its the most boring task in the universe.) If they are stressors learn to find resources to deal with them, ask for help, chunk up the task.
  2. Self-acceptance : nobody likes everything about themselves (thats why change and growth is lifelong) but we should all be able to accept who we are. Sometimes this is a major issue. Sometimes it isnt.
  3. A healthy diet, keeping active and getting a good sleep work wonders
  4. the five ways to wellbeing are important. They can also help establish patterns for you
  5. Know your pressure points and weaknesses and know what to do about them
  6. Be gentle with yourself – most of us serve because we need to be needed. recognise explicitly your motivation, work our the positives and risks of those and what you will do
  7. spend some time working through a guide to resilience such as Derek Mowbrays
  8. Work out a rhythm to life. And when it goes wrong, try to bring it back. Include down time and personal time in that rhythm
  9. Share, reflect and refine
  10. your self care strategy will really NOT be the same as anyone else’s. Take what works for you from theirs, but you are not them
  11. Your plan should cover your attitude to life, your way of keeping pace, learning and leading, down time and what for you is your bottom line. For some folk their bottom line is “leave me alone on Saturdays” for others its very different

Doing this in a group, where you feel safe to share, can be a really good exercise.

Dame Rennie Fitchie, the erstwhile Civil Service Commissioner, once said to a group of us that she worked out the demands made on her by a large jar of little blue glass pebbles. One for every day of the working year. And in those pebbles were four red pebbles, which was the number of weekends she was prepared to give up, because her weekends were precious.

For what it’s worth, here is my self-care strategy:

My attitude to life

  1. My motivation is to try to do as much good as I can, for as many people as I can, for as long as I can.
  2. There are only so many things I am prepared to take seriously. Life’s too short.
  3. I will have fun while I’m doing that, and I will squeeze every possible drop of enjoyment out of life
  4. I do have a cynical tendency. I will try to be the kind of cynic who sees and pokes fun at things which are wrong as part of efforts to change them rather than the type who gets bitter and angry, especially when people take the piss
  5. I do like manners and basic courtesy. They cost nothing and deliver much.  And I like them being reciprocated. Nothing is worse than a churl. And while I will try subtly to address this, occasionally I will make it obvious you’re being a churl or are otherwise taking the piss and need to stop.
  6. Whimsy is restorative (see item 9 below.)
  7. I will not beat myself up for failing in any of these.
  8. I will learn from my heroes. St Edith Stein said “the world doesn’t need what you have, but who you are”.
  9. I will regularly switch my brain off for periods of being a kid again.
  10. I am regularly double booked. I cant bilocate so I will do as much as I can and not stress about it. You shouldnt either.

Leading, learning and working

  1. I will never stop learning but I wont worry that I cant keep up with everything
  2. I will not sweat the small stuff. Seriously, I really won’t.
  3. But I will sometimes take delight in the good small stuff (someone buys me a cuppa or the recent issue by ADPH of lapel badges for its members had me almost dancing with joy, which I’m sure came across as odd.)
  4. I will remember in times of frustration all organisations and partnerships are dysfunctional, because they are human. (See point 4 above and points 5 and 6 below.) There is almost nothing that cannot be made worse before it is made better by giving it to a committee or partnership. That is the joy and frustration of being human.
  5. Nothing winds me up more than partnerships where one party wants everything on their terms. Thats a neuralgic point for me and I try to watch it. But be aware that this usually means I will seek every way of evening out the playing field even if you dont like it and it leads to confrontation.
  6. I will sometime tell you where to get off. Especially if you or your organisation are taking the piss. And if I feel you have the emotional intelligence of a doorstep I may do that very pointedly. I expect mature relationships. Deal with it.
  7. will appraise every stressor, and if I dont feel I have the resources to not be stressed by it I will ask for help
  8. I will rely on others and trust them.
  9. I will usually have a plan  B, and a plan C and D.
  10. 9 above and frequently smiling makes people regularly wonder what I’m up to and that can be an immense source of amusement and opportunity.
  11. I will lead with and learn from others and be led by them, I do not know everything
  12. I will get things done. On Monday I will look at what I need to do and on Friday I will look at what I have done.
  13. The “to do list” like death and taxes, is always with us. I will not stress about it

Pace, Health and Life

  1. There is, always, time for a cuppa
  2. I will enjoy the fact my eating healthily and being active gives me buckets of energy
  3. I will remember that the day after leg day and deadlift day when I have trouble walking
  4. I will have a treat/ cheat meal now and again . Especially if it’s chocolate covered or comes in cake form.
  5. The service of people brings me closer to why I am here. I will be energized by that
  6. I will have down time and personal time : every day
  7. I will have a lunch break
  8. I will protect some gym time, prayer time, family time and sad nerdy science fiction time. Nothing gets in the way of these.
  9. I will allow myself to moan and whinge and then remember these principles in case I allow it to get too much
  10. I will be choosy about how many weekends I will be prepared to give up for service/work/volunteering.

The bottom line

  1. I will not apologise for who I am.
  2. My faith is an explicit motivator for me, and a vital source of grace and challenge and renewal and replenishment and I am not going to apologise for that. I’m sorry if that’s a problem for you but it’s the core of my functioning, understanding of life and ability to serve.
  3. Like Catherine of Siena I believe that if we can be who we were made to be, we will set the world on fire.

Anyway, my self care is leading me to a cycle, a steak, a gym session and the cinema. Have a wonderful weekend folks





The Sugar Tax…I love joined up thinking

I love joined up thinking on building a healthy, economically thriving population. Unfortunately my penchant for analysing everything that comes in my direction tells me that’s not what we got today on sugar.

A taxing issue

The Chancellor has announced in the Budget, within the last couple of hours, a levy on the manufacturers of sugar sweetened drinks. I nearly fell off my chair. There are various bits of various devils to be included in detail but:

  • it will be graded,
  • it will come in two years from now,
  •  there will be a consultation (but basically we know it’ll happen)
  • it will raise £530m for spending on school sports
  • some drinks may be banned altogether
  • Some speculation breakfast clubs included (good idea and wholeheartedly support this)

A victory for public health, I hear some acclaim. Well, I can agree that health motives were stated as front and centre in the Chancellor’s thinking today on this one.

But a victory?  I’m not so sure.  A little cool-headed policy analysis suggests to some of us that this is only one measure – however welcome it is – among a range of measures we need to get our population to a healthy weight.

The Cabinet Minister and Paymaster General Matt Hancock MP is saying on BBC news as I write this  that the evidence for sugar tax is “pretty strong, and overwhelming.” I think that’s a little overstated. The evidence suggests a tax would lead to reduction in consumption, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/470179/Sugar_reduction_The_evidence_for_action.pdf but we also need other measures too. The BBC suggest this is a government turnaround from what was said earlier in the year.

What’s good about this

It’s great that money is being pumped into school sport. Sport is great for children for all sorts of biological, psychological and social reasons. Wonderful!  A rousing cheer. Brilliant move. I couldn’t be happier in and of itself just because of the wonderful benefits physical activity can bring to physical, cognitive and social development of young people. And putting some money behind our vital schools in their role of socialising the future of our country – our children – is great. But let’s remember some schools are struggling to deliver free school meals with the money they have already.

Here comes the but…

But however welcome the £530m is, sport in and of itself is not the answer to obesity. It can and should be part of an answer. But a nuanced reading of the evidence suggests that however useful a tax might be it isnt a solution in and of itself .  This tax measure wasn’t nuanced. There are all sorts of sources of junk calories in childrens’ diets way beyond sugary drinks, and all sorts of influences to help us gain weight that no amount of sports lessons will outweigh. This tax wont touch any of that. We still need a joined up obesity strategy.

Diet is hugely important for healthy weight. Physical activity is also hugely important but no amount of sport will save you from an appalling diet. The best way to keep a healthy weight is eat right AND exercise, not just exercise.

So from my own public health perspective, the logic here feels a bit awry. I know others disagree with me. Spending more money on school sports is immensely welcome, but that  won’t replace the cuts to obesity programmes because of cuts in public health money.

We’ve had 16% cuts announced over four years to public health budgets, budgets which fund child healthy weight services. However much putting money into schools and school sports is something I think is great, it does feel like with one hand a significant amount of money at least some of which was being spent on effective obesity reduction interventions has been taken away, to be replaced by £530m from a tax source to fund something which however good it is will not of itself be even the major factor in getting our population back to a healthy weight.

Whatever else it is, this is not a victory for joined up public health, or joined up thinking.

Better ways of spending £530m

I don’t want to appear churlish; but  this in and of itself will not give us the answer to child obesity. We need other measures too, so we still await the obesity strategy coming later in the year.  Using the money to deliver whole school approaches to healthy weight (cooking classes, healthy eating across the day, engaging parents in those, physical activity across the day) would be better.

Please, Sir, I want some more…

Tomorrow we have the LGA national event to look at what we’d like from the Obesity Strategy.  Reformulation of food, access to services, ability of local councils to fund healthy weight services, whole school day approaches to nutrition and restrictions on marketing to kids. Local and National measures have to work together to reduce the growth in unhealthy weight. This tax, and the money it generates, is just one measure. And frankly I doubt it’s the most important.

If this tax is all we get, it will not deliver the change we need as a population. As one measure among others, it is welcome. But it isn’t comprehensive and we shouldnt be distracted by the fact that this is political move as much as it is a public health one.

It’s brilliant that government really wants to do something on keeping our population healthy. Now let’s have something more effective than this.