Speaker1: [00:00:00] People live longer and healthier and therefore are more economically productive. Life is not equal or fair for everyone. Change is now the new normal. This is not just for the long term. So we view public health as an art. All of us lose and that is how you affect change. Primary care infrastructure. That is where you can have really effective public health taking place. We have to hold ourselves accountable. What that does is that it systematically advantages some groups. In that diversity is our strength. Taking a stand is an active process.

Speaker2: [00:00:35] Voices of Care, the healthcare podcast.

Speaker3: [00:00:38] Professor Kevin Fenton. Kevin, I'm delighted and honoured to welcome you to Voices of Care. Thank you for coming over in a very busy schedule and making time.

Speaker1: [00:00:46] I'm so glad to be here. It's been quite a long time coming and I'm looking forward to the conversation today.

Speaker3: [00:00:51] Likewise, I say good things come to those that wait. So we were absolutely delighted. I'd like to start, if I may. It's an exciting time for public health. I think it's three year anniversary coming up since your appointment as the President of the Faculty of Public Health. And it's a term we're seeing a lot at the moment. I'd love to start with a definition of it. Now, we don't have to go back to 1842 and Edwin Chadwick and all of these type of things. I read somewhere from the faculty that any definition of public health should begin with understanding what purpose it's serving. I'd love to hear from you, how we define that term, because it's quite an all encompassing term.

Speaker1: [00:01:35] Well, I'm so happy that we're starting with this definition of public health, because I think it's going to frame the conversation that we'll have today. So we view public health as an art and a science of preventing disease, of promoting health, of tackling health inequalities. And it's achieved through the organised efforts of society. And that definition really says that actually, not only do we rely on improving health and tackling inequalities through evidence, the science, but we also do it through the art because it requires tough decision making. It requires us to think of the ethics, the implementation, how we engage hearts and minds around the work that we do. And it also reinforces that public health is about not just individual actions by physicians or people in the health service, but everyone in society has a role to play. Businesses, academics, education, local communities all have a part to play. So public health by its definition, is inclusive. It is collective. It is built on principles of social justice because it's creating fairer societies. It helps us to tackle some of the difficult issues who's being left behind, who's not engaged. And what can we do to improve them? And ultimately it's working towards greater equity and better health impact for all. And of course, this means that it relates to economic productivity and economic growth and lower pressures on health and care systems and much more engaged and cohesive communities. And that's what public health is about.

Speaker3: [00:03:19] Well, thank you for that. And in a sentence, it's really a clarion call for us to understand that it's all of us that's involved. And it goes beyond, as you said, the strictures of the Department of Health or any other organisations.

Speaker1: [00:03:35] That's right. Now, the challenge, of course, is if sometimes people think, well, public health is everybody's business, but nobody's business. Right. But what we are saying is actually this broader definition of what creates health, what generates health allows us to think not only of high quality clinical care services, which is often where we go to first when we think about improving health of individuals or communities. But it also means that our housing, the transportation, the neighbourhoods that we have, the spaces that we have all have a role to play in improving health. And that's what public health specialists do. We bring people together. We create coalitions that can help to achieve positive change.

Speaker3: [00:04:19] Absolutely. And we won't have time to outline the full architecture. But Public Health England, of course, is four years since Public Health England was split. The UK Health Security Agency and the Office for Health Improvement and Disparities, of which you are representing here. Tell us a little bit about the fact that actually that collaboration is across all different sectors and segments of social care, voluntary sectors, as well as local authorities.

Speaker1: [00:04:49] That's right. So the English healthcare system is itself quite complex. And there are many players working at the national, regional, local and community levels which are all engaged in providing high quality healthcare. Public health physicians and public health practitioners also operate at multiple levels in the system. You've articulated some of the national roles that we have, either working in the UK Health Security Agency, protecting us against infectious diseases and other threats. Many public health practitioners working in the NHS helping to commission high quality NHS services. And myself and others work in the Department of Health informing and supporting government policy. But we also have public health people working in regions also in ICBs as well. Again, doing that work of bringing that thinking about population health, population health management, tackling inequalities to the NHS at that level, but also working with regional government. For example, I work with the Mayor of London as his statutory health adviser. And then at the local level, you have public health practitioners who are supporting implementation of the public health grant in local authorities, working with neighbourhoods and local communities, working with GP practices and the primary care infrastructure. That is where you can have really effective public health taking place at the local level. But all of these levels are connected because we work together as a system and as colleagues to ensure that in all conversations, we keep that light being shown on health inequalities, on improving health and on promoting health.

Speaker3: [00:06:28] And that's never been more important. Let's move from what to why? Because you've talked and articulated ever so eloquently and typically eloquently these multifaceted aspects of public health. It comes at a time where, 15 years after Marmot, we have statistics that are showing. Perhaps you can shine a light on why this is so important. The one that struck me, I think the UK Health Security Agency produced a report in May highlighting the fact that those in the bottom 20% of the most deprived areas carry the greatest burden. We've seen life expectancy reverse for certain groups.

Speaker1: [00:07:06] That's right. So, you know, as we've emerged from the Covid-19 pandemic, it is clear that not only do we have to deal with the short and long term impacts of Covid itself, but you remember we went straight into the cost of living crisis, and we've gone into a number of health and care challenges over that period. From a public health perspective, some of the big challenges we're looking at is the changing demographic profile of the population, that we are an ageing population, and that means more prone to higher likelihood and higher prevalence of many chronic diseases and diseases of ageing. Over the past few years, we've seen new patterns of infectious diseases emerge and a resurgence of vaccine preventable diseases such as measles. New conditions such as mpox have appeared. You add to that the climate crisis and how that's driving new patterns of disease and new challenges that we can face. And of course, the social and economic challenges of rising poverty. Issues related to social cohesion, employment, engagement in society will all have an impact on health, but also on health inequalities. Now, what we also know is not only are we seeing these challenges, but they're not randomly distributed in the population. And as you said, those who live in the most deprived parts of our communities are the ones that bear disproportionate burden of the ill health, the impacts of climate change, the impacts of multiple challenges that can affect their health, poor housing, poor access to public transportation, lack of access to green and blue spaces. In other words, nature to help to improve their health and well-being. So any strategy that we have must take into account that not only do we provide universal services for everyone, but we need to target the interventions and resources that we have to those who are most likely to be left behind.

Speaker3: [00:09:01] And actually, it's very timely, I guess, for public health practitioners and physicians. Exciting, even. I don't necessarily use that term always because it's such a transformative time, but the government has stipulated in its manifesto that one of the commitments it's going to make is to attack these social determinants and to halve the gap in healthy life expectancy. So we saw recently the public health grant a significant increase. You must be quite pleased to see that.

Speaker1: [00:09:33] Well, anything that would invest more into the primary prevention and early intervention of part of the sort of pathway in how we improve health is going to be a welcome thing for too long. Healthcare systems in many countries around the world differentially invest in high quality clinical services, high technology, rather than the basics of engaging, empowering and helping people to be healthy and to prevent disease. So the investment in the public health grant is welcome. It has come at the back of years of consistent declines in funding, but this increase in funding, plus the government's commitment to shift its focus from treatment to prevention, from hospital to community and from analogue to digital. Three ambitions of the government which can help to fundamentally reshape how we view health and healthcare in the population, is exciting. So it means that with additional monies and investment in the public health grant, we can do some of the real work that needs to be done of investing in prevention, tackling inequalities, mobilising communities and helping to build resilience for populations because that's needed for economic growth and productivity. And it's needed to take the pressure off of the health services.

Speaker3: [00:10:59] Absolutely. And I think the background, as you said, I think the stats from the Health Foundation show that the public health proportion went from 2.9% about ten, 12 years ago to 2.2 of the overall NHS budget. Thea Stein called it the poor relation of the NHS and the healthcare service. Expand a bit about, if I may, from you that I've heard and read that actually the investment, because we're still going to be a country that spends £3,000 per person on acute settings and 700 on prevention, but the value for money, the return on investment is very significant compared to an acute intervention to make a big difference in healthy life.

Speaker1: [00:11:40] That's absolutely right. You know, we have the best buys in public health and in prevention. So if you help someone to quit smoking, for example, that has a huge impact both on reducing healthcare costs because you're preventing respiratory diseases and cancers and other adverse health outcomes, and people live longer and healthier and therefore are more economically productive. So your return on investments, on really effective interventions, helping people to stop smoking, helping people to cut down on alcohol, maintaining a healthy weight or tackling obesity. All of these have direct impacts on costs. Now, one of the other things you often hear people say is, well, you know, Kevin, if I invest in public health now, I'm not going to see the returns until 10 or 20 years ago. And I want to just end that thinking now, because public health has the ability and does have much faster return on investments. If you stop smoking today, we begin to see the benefits for your health appearing within weeks or months because it reduces your ability to acquire respiratory tract infections, it can reduce your short term ability to have cardiac events, especially if you're an older smoker who's obese. And if you begin to tackle some of these issues together so you stop smoking, become more physically active, reduce weight that begins to increase the time, and decrease the time in which you begin to see those benefits. So public health is both for the long term, but also results in short term benefits, especially to the health and care system as well. And we really want to get that thinking into everybody's head that this is not just for the long term, but also for the short term.

Speaker3: [00:13:24] Which of course is going to be very beneficial politically. And also from the economic perspective, as you've mentioned. I wanted to tackle, if I may, you talked earlier around the definition of public health and that it's embedded in a field of values and of course, within the context of politics and injustice or social justice. You've been very passionate for many years to talk about one aspect of that social justice of public health and its interface with racism. And I wanted to bring that out because you've called it out. You've said racism is a public health issue.

Speaker1: [00:14:04] Yes. So, you know, when we are talking about the factors which are driving health inequalities, especially through the lens of racial and ethnic health inequalities, I think it's important that we are able to be clear and honest about all the factors which are driving those racial and ethnic health inequalities. So in addition to whether it's poor housing or poor access to healthcare services or poor job opportunities or other social determinants of health, we now know that structural racism is also a factor which independently has an impact and drives poor outcomes for racial and ethnic minorities. Now, what is structural racism? Maybe. Let's start with a definition that helps people to understand what we mean and why it's important. Now there are many definitions, but the one which I think is really helpful is viewing structural racism as a system of structuring opportunities. Right. And that system of structuring opportunities is based on your physical characteristics, the colour of your skin. But what that does is that it systematically advantages some groups. And it's systematically disadvantages other groups. But the net impact of this system of structuring opportunities is that it saps the strength of the entire society. So all of us lose because of the way we're building in advantage and disadvantage based on the colour of our skin.

Speaker3: [00:15:33] And I think that's important to bring it. I'm glad you did that with structural racism. Just to bring that to life for me when I was preparing to talk to you. I think the Health Foundation, Runnymede Trust did some important work this year, and there's a number of things that they highlighted around housing and income and employment opportunities. The thing that struck me was, I think they found that 60% of people from Pakistani or Bangladeshi backgrounds, 50% from a black minority ethnic background, are more to be found in children are found in poverty, compared to 25% amongst white children. So that brings home to me as someone who grew up in poverty in London. So this is a real life, consequence of this structural racism you're talking about. And it actually costs the economy and our overall well-being.

Speaker1: [00:16:19] That's right. In fact, we commissioned Professor Sir Michael Marmot in the Institute of Health Equity to do a review of the impact of structural racism in London. And his review really showed that even in a culturally diverse city such as ours, with 10 million people, that the experience of Londoners varies differently according to the racial and ethnic background and their experience of structural racism. This has an impact, for example, on their job opportunities, their educational attainment, the way they feel connected to their local communities, the way they feel safe in local communities. Structural racism has an impact on how people are able to access and trust healthcare services, and it also has an impact on the quality of services that they receive and therefore the outcomes that they have in terms of when they engage with the health service. And what he also has shown is even when you have a good education and great education, as we do in the city, the long term experiences of black and minority Londoners over time for some groups still is disadvantaged because of their experience in the workplace, their experience with the criminal justice system, etc. So by speaking about this and identifying it, it's not necessary to say this is the only factor that we need to grapple with. But what we are saying is, if you're going to be taking a holistic and comprehensive approach to tackling inequalities, then understanding the role of structural racism that it plays will help you to do a much better job of tackling these long term entrenched health inequalities which predated Covid, but which have been exacerbated by the pandemic. And now it is so important for us to get everyone back on track with their health and wellbeing.

Speaker3: [00:18:06] And to speak, please, a little bit in terms of the importance of the language that is going to be used because we use racism, structural racism, we identify whole groups by particular language, and that may be required for a variety of statutory and other reasons. But I think you've been on record saying that we actually also got to be very careful in the language we use, because that itself can potentially impact outcomes and experiences.

Speaker1: [00:18:31] That's right. And one of the things we've learned is that the experiences of different ethnic groups are not the same, right? So that is why, coming back to those principles of public health, of really looking at your data, of engaging communities, of understanding those variations, and then working with those communities to develop tailored solutions, must be part of how we do better for everyone. And in fact, that's what Covid taught us, right? So when we had to do Covid testing or we were rolling out the Covid vaccination programmes, we saw these huge variations across the city in people willing to accept the vaccine and to get vaccinated. But any strategy to improve vaccination rates across the city required us to go into communities, to build that trust, to listen to what were the challenges communities experienced and then to develop bespoke strategies with them. We could not have got through the Covid pandemic without that deep work with our communities to listen to their concerns and to really develop approaches in partnership with them. That made a difference, and that's been one of the lessons from the pandemic, and I hope it will be a legacy from the pandemic that that deep community work, engagement, building trust must be part of delivering effective healthcare services for everyone.

Speaker3: [00:19:51] And no one can disagree. That would be a wonderful legacy to carry on. Are you seeing evidence of that? Because trust I think very recently, if you look at just vaccination rates we've had quite recently, they vary very significantly and broadly for London, if we take the umbrella term for certain age groups and minorities, the vaccination rates vary incredibly. So that trust is a work in progress, I guess.

Speaker1: [00:20:17] Exactly. And it requires an active process for each cohort and generation that we continue to pass the baton on what we're learning, what is working, and how do we continue to improve? You know, I'm really excited that in London over the past five years, we have learned lessons from the pandemic, both with a legacy programme on vaccination. The London Vaccine Health Equity Programme, which ensured that all of the work that we did with faith communities, with business leaders, with our minority communities across the city, we were able to maintain momentum and to bring that learning to help to inform our strategies for other vaccination and screening programmes. As part of the work that we've done throughout the pandemic on tackling structural racism, we now have commissioned and are working with a London collaboration on anti-racism, which brings the healthcare system's commitment to being anti-racist together to learn and share best and promising practice. So we're creating learning communities across the region where our commitment to be anti-racist and to tackle health inequalities means that we're sharing together and improving together. And all of this is underpinned by better data, both with the NHS staff and or communities to sense check. Are we moving in the right direction? Are we diversifying our workforces? Are the experiences of our workers improving as a result of our actions? We have to hold ourselves accountable and we have to measure the progress that we're making. And that's been the London journey of the past five years. It's different, it's unique, but it's needed because of our experience in Covid and what we know of the needs of Londoners.

Speaker3: [00:21:59] And it's interesting as a city example, just to put it into a more national or international context. London is not unique in having a quite significant diversity within its own diverse populations. I think you're very familiar with, I think Paris, Berlin, other cities around the world.

Speaker1: [00:22:15] Yes, absolutely. And in that diversity is our strength, right? It's what makes the city a fantastic place to be in and to live in. And I'm so privileged to be the public health director for this amazing place. And so for me, it's about giving everyone both the best chance to have a fairer, healthier, more economically productive life in the city. It's also about being connected to who we are as Londoners, because in that cohesion gives us resilience as a community, and that resilience helps us to deal with whatever shocks will come in the here and now. And so think of it in terms of the gains to be made by saying, actually, we recognise that life is not equal or fair for everyone, and we're deliberate in our thinking about how we structure the healthcare system or social care system or public health system in helping all Londoners to have a fairer outcome.

Speaker3: [00:23:10] I wanted to move on to some of the victories and successes that we can draw upon, to show that actually public health interventions can make a big difference. But before that, if I may, I want to go back to the term that you used was anti-racist. And that's a term of art. And I just want you to unpack that because that goes to the language we use and tackling the categorisation of people according to particular pre-assumptions.

Speaker1: [00:23:36] Yes. Well, you know, the theory on racism is that what really will change it is when we all take a stand against it. And that taking a stand is an active process and therefore being anti-racist. It's not just saying I'm not a racist, it's saying, actually, I'm going to be part of helping to dismantle this system of structuring opportunities that I spoke about earlier in a deliberate and intentional way. It means for all of us of whatever ethnic backgrounds, identifying and being able to talk about racism in a way that isn't threatening or challenging, but to saying, actually, here's a problem that together we need to address. It is about all of us understanding how structural racism or racism is operating and where we're working and where we're living. How is racism resulting in differences, and therefore, what are we doing to help to address that in terms of dismantling that. And it also means taking individual action as well. So whether it's having these conversations, supporting a colleague, whether it's being an advocate, there are things that we can do as individuals or collectively to help to address these long-standing and systemic differences. And that's what being anti-racist is about. I often say, say it, name racism, talk about it. Because in talking about it, you enable others to be able to have tough conversations. See it, see how it's operating where you are, and then act on it. Do one thing in your power that can make that difference.

Speaker3: [00:25:08] Absolutely. And I think, I guess that is the apotheosis of the organised effort of society definition of public health. Thank you for that. I wanted just to have a couple of examples or more broadly, tackling health inequalities wherever they may manifest. If you can share some examples from London. There's been some great examples in Manchester and Newham as well, but. And we could be here for a long time, but I just wanted to get some ideas around where public health interventions have measurably made an impact. I'm thinking, of course around the tobacco, sugar, obesity, but I'll leave you to have the platform because it's fascinating to see how that's developed. It's a nudge society, but a bit more than that, I think.

Speaker1: [00:25:51] So I'm going to give you three examples. You know, I could really do an entire podcast on this, but you will see and hear the excitement in my voice when I talk about how working together we can achieve great things. So the first is London and you may not know this London is leading the world globally in reducing new HIV diagnoses. It's been a journey that we've been on over the past two decades, and the pace at which we've been declining new HIV infections is because of our ability to work across NHS, local government with our partners to really focus on the things that work for tackling HIV, for tackling stigma, getting people into care, and virally suppressing the virus so that we reduce the likelihood of transmitting HIV. We still have a way to go, but globally our way of working together as a city. In our Fast Track Cities programme of commissioning HIV preventive services through the Do It London programme and the collaboration across systems is really making a difference.

Speaker3: [00:26:54] And if I may bring to this not only your obvious passion and excitement, which I can see, but also years of experience. I think this was a topic which was very close to your professional heart in the United States.

Speaker1: [00:27:05] Absolutely. So I qualified in medicine in 1990, and in fact, one of the reasons why I went into medicine was that I saw in the 1980s those early cases of AIDS and an unknown disease and the fear and stigma that it was causing then. So for me to be at midway of my career, helping to end this global pandemic is wonderful, and for London to be leading that because of our collective action is incredible. A second example is our work on tobacco. You would not know this, but London has lower rates of smoking than England, and we've been on a declining trajectory again over the past two decades. And that really is a combination of really effective actions on stop smoking services in the NHS, supported by local government. We worked together in the London Tobacco Alliance, where we're always looking at the data, looking at which communities we need to work with, using all of the tools in the tobacco prevention toolkit. So education and campaigns services to help people to stop smoking, really thinking about laws and regulations that can help. And of course, tackling new threats such as the threats of youth vaping. Of course, all of that is because we're working together as a partnership and we're able to deliver.

And then the last example I'm going to give you and hopefully you won't edit this out. But this is around how do we tackle a big driver of mortality in the city which is cardiovascular disease. And we've really been thinking, you know, London is so big and there are pockets of really lots of great intervention. But how do we come together to really focus on heart health in the city? And we've never had a heart health initiative in London. And working with our partners in the NHS in London councils, local government, we've come together on a campaign called the Million Hearts and Minds Campaign, which is a phenomenal cardiovascular disease prevention programme which builds in from the front end community engagement, mobilisation and empowerment. Working with the clinical systems, we're engaging workplaces and employers to really think about their heart health initiative. But building this on great population health data and clinical data and research. Phenomenal way of working together, more coalition of partners coming together. And that is how you affect change. It's not one by one, but all of us working together with a shared mission, shared values for change.

Speaker3: [00:29:32] Public health clearly works there. One final element, if I can, just to get your view. You've been a celebrated and deeply respected leader for a very long time. And as we now move into, I don't want to call it a new landscape, it's definitely it feels like a watershed NHS ten year plan, the Casey Commission for Social Care, many different changes taking place ICBs having to perhaps look at themselves and how they're going to reorganise themselves. Talk a little bit about the hope you have of public health's space within that new architecture, and the importance of leadership for public health.

Speaker1: [00:30:13] What a wonderful way to end the reflection. You know, one of the things I say to colleagues is I know it can feel challenging and discombobulating and disconcerting to be in the midst of all this change and uncertainty. And it truly is a tough time. And I can see the impact it's having on our staff, on our communities. We're grappling with so many threats. One of the things I tried to say to colleagues is reframe. This change is now the new normal. Things are happening faster, not just in terms of transformations of the healthcare system, but life in general is happening faster. So the more that you can be resilient, the more that you can embrace change. And to look for opportunities in that change is the more you're able to take a little bit of control and to have some influence on the outcome. And that really helps. So as we're going through all of this, we embrace the excitement and the promise of the ten year health plan, and we embrace the changes which will happen in the health system. And we will have to use this opportunity to ensure that prevention, primary and secondary prevention that I focus on, health inequalities becomes part of the DNA of the new health and care system. So whether you're working in the Department of Health, whether you're in a region, in an ICB or in a neighbourhood, because neighbourhoods are going to be where the action happens.

Speaker3: [00:31:38] Absolutely.

Speaker1: [00:31:39] We begin to think about what is the prevention dividend and how do we use our assets at that level to help to improve health. And what I'm hoping are three things. One, that we remember the centrality of engaging our communities in all of this design. We've just done the consultation on ten year health plan, tens of thousands, if not hundreds of thousands engaged. Let's continue to bring their voices in. Second, ensure that we build in good data and evidence. So even when there's limited evidence, we commit to evaluation. But to be honest, we have a good sense of what works and good best values. And then finally ensuring that the system is cohesive and joined up. So we're thinking about the public health and prevention dividend in everything we do.

Speaker3: [00:32:28] On that extraordinarily inspiring note. It was well worth the wait to have you here. Kevin, thank you so much for sharing your wisdom, and I hope you'll come back again as the new era unfolds to give us an update and insights.

Speaker1: [00:32:42] Thank you so much. It's been such a pleasure.

Speaker3: [00:32:45] Pleasure. Thank you. If you've enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to find out more about how we're turning the dial on health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us today, and I look forward to seeing you on the next episode.

Speaker2: [00:33:06] Voices of Care, the healthcare podcast.