Gateshead Council Director of Public Health Alice Wiseman on how local government is the right home for public health and why it needs to use its influence to take on the might of industry.
Alice Wiseman has seen public health from both sides – and she knowns which one she prefers.
The move into local government has opened doors to working with the community that were simply not there when public health was in the NHS.
Ms Wiseman, who took up the post as director of public health in 2016, previously worked as a public health consultant in both the NHS and local government.
“For me the move back meant public health was returning where it should be. Things that really make a difference to population health sit in councils. If you increase employment, if you reduce poverty or if you improve housing those things will all have a greater impact than just treating illness or stopping an illness getting worse.
“But in the NHS the focus was, understandably, nearly always on downstream illness and disease and while this is part of improving health it is only a small part – around 10 to 20 per cent of population health outcomes. We are now working with communities in a way we would not have done in the NHS.”
Reaching out to most disadvantaged
Ms Wiseman said this has helped public health reach out to the most disadvantaged groups in the population in particular.
“For example, we’ve been working in the ward with the highest levels of childhood obesity. We’ve embedded a researcher in a community organisation to understand the issue and potential solutions from the perspectives of the families living on that estate.
“People are worried about their children going to bed hungry so cheap accessible junk food is seen as the only option. Working with the community they found their own solutions, for example, a healthy pizza stall open on a Friday night.”
Alongside this, the community worked with planning and highways to make road safety improvements around the school to encourage more walking to school.
Another example of the work, Ms Wiseman said, was the introduction of new planning policy in 2015 that restricted new fast food outlets near schools, in areas where there was already a high number and in areas where child obesity rates were judged to be high. It has reduced the number of takeaways by 14 per cent over the past seven years.
“These examples show what can be achieved when you are in local government. Previously we would probably have looked at the figures and done something to educate them – and dare I say it, without understanding the context of people’s lives, it patronised them. Now we are, I hope, finding solutions that will work,” she said.
‘We have to use our voice’
But Ms Wiseman fears the pandemic may have taken public health 'back a couple of steps' - and not just because of the disruption to services and lost momentum.
“It had taken time, but we really had established our role in local government. However, I fear COVID-19 has perhaps typecast us, to the wider public and partners, as solely focussed on infectious disease and a medical approach to issues. It could undo some of the relationships that have developed. We perhaps have to work to re-establish the remit we have."
But one set of relationships that COVID-19 has strengthened is the one between fellow directors of public health. “It really brought us together. We had to support each other because of the demands being placed on us. We have found a real collective voice.”
And that voice will be needed in the coming years given the challenges that are being faced. “We need to use it to influence policy,” Ms Wiseman said.
A major concern of hers is budgets.
“We’ve had significant cuts to our budgets in public health – our commissioned services are on the edge. But I am also worried about the wider council budgets.
“It affects our ability to provide other services, such as early help for children.
It is getting to the point that it is only when it gets to a safeguarding stage that we have the resources to act. But prevention is always better than picking up the pieces in a crisis.
Alcohol, gambling and unhealthy food
The influence of industry – alcohol, gambling and unhealthy food – is also a big challenge, she said.
“We’ve done a fair job with tobacco, but we have got a long way to go with alcohol, gambling and unhealthy food.
We have to ask ourselves how we’re going to better protect people from the aggressive marketing, pricing and availability of these products. A few decades ago when 80 per cent were smoking we would never have thought we would get to where we have got now. We have to have the same ambitions in these other areas.
“We have banned point of sale displays, plain packaging and smoking in public places. I am not advocating exactly the same for alcohol. I know we will never stop drinking altogether, but we can take steps to de-normalise it and protect the next generation from aggressive marketing. Minimum pricing is not silver bullet, but evidence emerging in Scotland suggests it does have an impact.
“I know people say they don’t like the nanny state telling them what to do, but at the moment industry is dictating how we behave and think about these harmful commodities.
“There needs to be greater awareness. Alcohol is empty calories, but we don’t provide nutritional content on drinks, and it is linked to seven different cancers and obesity, but people don’t tend to know that. Then there is the impact on hospital admissions, deaths and even police assaults – the cost to society as well as the individual is huge.
“I am also worried about gambling. People are getting themselves into debt, it is driving criminal behaviours. We are walking into a crisis with our eyes tight shut.”
Ms Wiseman acknowledges much of this requires a national policy response, but she said councils should be given extra powers too.
“Health should be a licensing objective. I can make the case for crime and disorder and the protection of young people, but licensing committee can still not take into account impact on health. It should be able to do.”
But it also, again, comes down to budgets. “If we were better resourced we would be better able to enforce the powers we do have. When we do test purchases for alcohol and vapes being sold to under 18s we often find outlets not keeping to the law. But we are limited in how many test purchases we can do because trading standards are stretched. With more funding, we could have more of an impact.”