Public health & politics F EAT U RIN G Interviews with Registrars on government placements ReďŹ‚ections from Registrars on politicians And SO much more!
PH1 AUGUST 2015 PUBLIC HEALTH AND POLITICS
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2) What's that wee system you have there?
3) Interview with Vittal Katikireddi
4) Interview with Janine Thoulass
5) Scottish Public Health Review
6) Westminster and Holyrood—Spot the diference
7) ‘Legal Highs’
8) Legislation and Public Health - A journey though history!
9) Word Search
Cover Pictures: Buchannan St, Glasgow by Kenneth Williamson. Gorbals Tower Blocks Source: Wikimedia. Author: by Thomas Nugent. Eilean Donan Castle. Photo by: Stefan Krause. Licence: LAL Picture Opposite: Isle of Skye. Flickr. Moya Brenn
Header Font: Nouvau by Alan Cuins Stencils: Rennie Macintosh by The Stencil Library, www.stencil-library.co.uk
Welcome to the August PH1 edition! In light of the increasing divergence of public health delivery across the UK we thought we would begin by describing Scotland and the public health system here to put the issue into context.
Photo Source: Yael Ossowski
Although Scotland has a relatively small population of almost ﬁve and a half million, accounting for 8% of the UK's population, it covers nearly a third of the total land mass of the UK. The geography of Scotland varies from the major urban centres, which are predominantly in the central belt, to the vast expanses of remote and rural areas and islands. Interestingly, rural areas account for over 94% of the Scottish land mass but only about a ﬁfth of the total population.
NHS Scotland consists of 14 regional NHS Boards which have responsibility for the delivery of healthcare services and the protection and improvement of their population's health. There are also special NHS Boards and other national bodies, such as Health Protection Scotland, which all provide a range of specialist and national services to support the regional boards. In Scotland, the specialist public health function is largely located within Public Health Departments based in Health Boards. Therefore, those that work towards health promotion, health protection and improving services work collectively to improve the health of their populations in close collaboration with partners, such as Local Authorities and the Voluntary Sector, through processes such as the Community Planning Partnership. The co-location of the domains of public health is viewed as a key strength of public health delivery in Scotland. Co-location allows staﬀ to work across and between the domains, encourages sharing of expertise and experience, promotes resilience and eﬀective local capacity and enables coordination across a range of diﬀerent services. Scotland shares many of the public health challenges facing the rest of the UK although the remote and rural setting for a signiﬁcant proportion of the population provides additional challenges for supporting population health and wellbeing.
Background: 13 of the Scottish healthboards. Source NHS inform.
This issue of PH1 focusses on politics. It is becoming increasingly apparent to us just how much the political landscape impacts on the work public health seeks to deliver. Furthermore with the recent referendum, UK election and the looming spectre of a Scottish Public Health Review (instigated by the Scottish Government) we thought it would be an opportune time to consider politics as the theme for this Scottish PH1 edition. We start with Josie setting the scene and describing the Scottish Parliament and the Scottish Government and how they interface. We hear from three registrars who have recently done placements in the Scottish Government: Vittal who was developing policy work on health inequalities in addition to scoping regulations around cosmetic procedures (two unrelated projects!); Janine who had the opportunity to act up as Senior Medical Oﬃcer; and Esther who reﬂects on her experiences being involved with the current, ongoing Scottish Public Health Review. Moving back to the Scottish Parliament aspect of politics, Josie spots the diﬀerences between the Scottish Parliament and the UK Parliament, Emma describes her unexpected brush with the Scottish Parliament and Jenny takes us on a journey through history recapping some of the key public health legislation (only some of which the MPH may introduce you to!). The issue ﬁnishes with a bit of fun on page 25. We hope you enjoy! Emma, Josie and Jenny THE EDITORIAL TEAM: EMMA FLETCHER JOSIE MURRAY JENNY WARES On behalf of the Scottish public health Registrar Group
Photos of the Editors: Emma, Josie and Jenny Emma Watson, by Giorges Biard, Uploaded by MyCanon. Wikipedia.org. Josie Gibson by Josie Murray Source FPH Today. Jennifer Garner Source Flickr by JonJames1986 under Creative Commons Attributes.
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PUBLIC HEALTH REGISTRAR INTERVIEWS WITH JANINE &VITTAL Two registrars, one CCT-ed, tell us what it is like to have a placement in the Government, and share their insights TO HEAR WHAT IT’S LIKE TO BE A REGISTRAR AT THE SCOTTISH GOVERNMENT PLEASE TURN TO PAGES 10 TO 14
SCOTTISH PUBLIC HEALTH REVIEW DESTINATION UNKNOWN Our co-chair of the Scottish Public Health Registrars group talks about being involved in the Public Health review process TO READ ABOUT THE PUBLIC HEALTH REVIEW IN SCOTLAND PLEASE TURN TO PAGE 15
PUBLIC HEALTH REGISTRAR WORKING WITH DRUGS Our own Emma describes her work on ‘Legal Highs’ and shares her reﬂections and learning from working with politicians. TO REGALE REGISTRARS EXPERIENCES WORKING WITH THE SCOTTISH PARLIAMENT PLEASE TURN TO PAGE 19
PUBLIC HEALTH LEGISLATION A JOURNEY THROUGH HISTORY Our own Jenny Wares gives us a ﬂavor of the legislation passed throughout the UK over the last few centuries TO JOURNEY THROUGH TIME WITH PUBLIC HEALTH LEGISLATION PLEASE TURN TO PAGE 21 Pictures from top to bottom. Isle of Staﬀa. Source: www.7themes.com. Turnberry Golf Course Source: www.turnberry.co.uk. The Kelpies. Source www.ieindependent by Andrew Milligan/PA Wire. Forth Rail Bridge. Source: www.7themes.com
PH1 AUGUST 2015 PUBLIC HEALTH AND POLITICS
WHAT’S THAT WEE SYSTEM YOU HAVE THERE? By Josie Murray
Solicitor General, and 129 positions for Members of
On the 1st of July 1999 the Scottish Parliament opened
The Scottish Parliament.
for the ﬁrst time in almost 300 years, and the
These MSPs are made up of 73 positions which are
formation of the Scottish Government (previously the
held by those voted in by a ﬁrst past the post system,
Scottish Executive) came into being.
from geographical constituencies. The further 56 seats
are voted by semi-proportional representation, using
The Scottish Parliament is the devolved national,
the Additional Member system for eight regions across
unicameral legislature of Scotland. Located in the
Holyrood area of the capital city, Edinburgh, it is
housed in the Scottish Parliament Building, opposite
Prior to the uniﬁcation of the Kingdom of Scotland and
Holyrood Palace, the residence of the reigning
England, the Parliament of Scotland, or the Estates of
monarch when they are in Scotland.
Scotland as it was known, was made up of the Three
The single legislative chamber is made up of 131 seats,
Estates: Bishops & Abbots, Nobility (landowners), and
two seats for the unelected Scottish Government Law
Burgh (Town) representatives, but all met within the
Oﬃcers: the Lord Advocate of Scotland, and the
Photo: Scottish Parliament building. Source: Scottish Parliament Page 7
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In the Act of Union in 1707, Scotland retained its own systems of law and justice, education and Church (Church of Scotland, Presbyterian polity), separately from the rest of the country. The union merged the Estates of Scotland with the Parliament of England to form the Parliament of Great Britain in Westminster with 45 seat for 48 constituencies for Scotland.
PROCEEDINGS Parliament is held on a Tuesday, Wednesday and Thursday from January to June and September to December. Mornings are usually reserved for
Prior to any meeting of full parliament in the debating chamber, a mace covered with gold panned from Scottish rivers is placed in front of the chamber. Photo: Scottish Parliament Mace. Scottish Parliament
committees, such as the Health & Sport Committee, and Wednesday afternoon and Thursday are for full
parliament meetings. The majority of work of the
The Parliament of the United Kingdom constitutes
parliament is done by committee. Each committee is
supreme legislation. Under the Scotland Acts 1998
made up of a number of MSPs from diﬀerent parties,
and 2012, the Parliament of the UK has devolved some
and mainly back benchers.
of its Scottish domestic policy to the Scottish Parliament. Devolved issues includes: agriculture, ﬁsheries and forestry, economic development, education, environment, food standards, health, home aﬀairs, law, local government, police and ﬁre services, sport, the arts, transport, training, tourism, research and statistics and social work. The Scottish Parliament also has the ability to alter income tax in Scotland by up to three pence in the pound. There is a speciﬁc list of reserved matters, but all those which fall out of this list are automatically devolved to the Scottish Parliament. The Scottish Parliament can pass legislation. They also hold the Scottish Government to account.
Unlike Westminster, the structure of the debating chamber is that of a semicircle- a design feature to represent a desire for consensus between parties. Photo: Scottish Parliament Chambers. Page 8
The Scottish Government ministers are supported by
The majority party in the Scottish Parliament forms
the civil service. The civil service remains a reserved
the Scottish Government. The head of the Scottish
issue – there are over 17,500 civil servants who support
Government is the First Minister, which technically
the ministers in Scotland. Whilst their standards are
could be any elected member of the Parliament, but in historically set and moulded by the UK civil service, practice ends up being the Leader of the Majority
they serve whichever ministers are in current
government position in Scotland.
The First minister then forms their cabinet, who make Within the government there is a Minister for Public up the Scottish
Health, currently Maureen Watt MSP.
cabinet, and therefore F U N C T I O N the Government. The Scottish Government’s purpose is to focus government and public services on creating a more Nicola Sturgeon, First Minister of Scotland. Scottish Government. Licence: OGL
successful country, with opportunities for all of Scotland to ﬂourish, through increasing sustainable economic growth. The wide range of functions is executed through ﬁve Directorates as follows: Enterprise & Environment;
Governance & Communities; Learning & Justice;
There are 10 positions in the Scottish cabinet, these
Health & Social Care and Finance.
are made of one First Minster and nine Cabinet Secretaries. There are a further 13 positions of Junior Ministers. There are then two cabinet sub-committees, one on Legislation, and the Scottish Government Resilience Room (ScGoRR). All cabinet meetings take place in Bute House, Edinburgh – the oﬃcial residence of the First Minister of Scotland.
The Scottish Government oversees all new Scottish policy developments and is ultimately responsible for most of the day-to-day issues which are of concern to the people of Scotland, including health, education, justice, rural aﬀairs, and transport. The Ministers and civil servants work to support the delivery of the Scottish Government’s ﬁve strategic core objectives: Wealthier and Fairer Scotland; Healthier Scotland; Safer and Stronger Scotland; Smarter Scotland and Greener Scotland. ~
Photo: Scottish Government. Page 9
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INTERVIEW WITH VITTAL KATIKIREDDI By Jenny Wares
The second project was within the Public Health Directorate and involved working with COSLA
You have been on placement in the
[Convention of Scottish Local Authorities] and NHS
Scottish Government, how did this
Health Scotland to develop a mechanism for
undertaking policy work on health inequalities. The most recent review of ‘Equally Well’ (Scottish
It is quite common for public health registrars in
Government’s policy on health inequalities)
Scotland to undertake an attachment with the
highlighted that although useful progress had been
Scottish Government and so organising it was easy.
made, many of the actions were not carried out at
These attachments require advanced planning so I
suﬃcient scale to have a meaningful impact on health
contacted the training coordinator within Scottish
inequalities. I worked with the lead civil servant to
Government about a year in advance to discuss a
develop an Inequalities Action Group.
potential placement (details below). Attachments are usually provided for a maximum of six months full -time equivalent.
What job were you doing?
What would a normal’ day entail for you in this role? The day to day job would probably look like most other public health roles in that meetings, preparing brieﬁng
I was working on two diﬀerent projects during my attachment. The larger of the two projects was based within the CMO [Chief Medical Oﬃcer] Directorate and was focused on scoping the options for regulation of cosmetic procedures in Scotland. The project arose because of concerns about patient safety since the private sector market is relatively unregulated; a ﬁnding which rose in prominence following the PIP [Poly Implant Prosthese] scandal. Recommendations for regulation were produced following an investigation for the Department of Health by Sir Bruce Keogh. However, given the legal and regulatory framework diﬀers in Scotland, further work was required to determine the implications of the recommendations for Scotland and how these could be implemented.
papers and liaising with colleagues were a predominant feature of the role. Having said this, the scale of the work is diﬀerent in that commonly registrars are involved with work at a Health Board or community level rather than a Scotland wide level and so you need to consider the implications for island communities right through to inner-city Glasgow. The process of working with civil servants enabled insight into government workings and the contribution of the policy and analytic teams. I also had the opportunity to write brieﬁngs for the Cabinet Secretary and ministerial speeches.
VITTAL (pictured right) HAS JUST COMPLETED SPECIALTY TRAINING AND IS DUE TO START A JOB AS CLINICAL FELLOW IN THE UNIVERSITY OF GLASGOW Page 10
What was the most rewarding aspect of the placement?
I would highly recommend a placement with Scottish Government; I would probably rate it as my top attachment and certainly learnt a considerable amount
For a trainee the placement provided a wealth of
during my time there. There are a huge range of
opportunities through the diﬀerent projects that were
opportunities within the government with respect to
available across a huge breadth of areas. As a result
public health – you are given the freedom to provide
you could tie in pieces of work with your interests and
public health leadership on pieces of work and are less
also any outstanding learning outcomes. The role also
shielded than you might be within a health board.
provided considerable autonomy in terms of taking
What do you consider to be the
projects forward and seeing work you’ve been involved
most significant public health
in having an observable impact on the real world was great.
What was the most challenging aspect of the placement? In keeping with other placements it was challenging at times to balance the competing priorities of the placement and my other academic commitments. Although the placement provided great insight into how government works, it was sometimes diﬃcult to know who to approach about certain issues as it was not always obvious initially. It enabled an appreciation of how the civil service works diﬀerently which was useful.
How do you think this placement helped you in your career development? Scotland is a small country, especially with respect to the public health community, and so it was incredibly useful to see how organisations relate to each other and to further the development of professional relationships.
What would you say to anyone
challenges in Scotland and how could these be addressed more effectively? I think a principal challenge relates to the commercial determinants of health and how these could be addressed. Scotland has made good progress with tobacco control and alcohol policy but the missing aspect is around obesity, in particular the amount of sugar and to a lesser amount fat in food and drinks. The second relates to managing the implications of demographic change and how to support health and social care systems to cope with an ageing population. There needs to be a greater role for shifting from curative care to a continuum of reduced treatments followed by palliative care. The third relates to sustainability and the role of public health in taking leadership, both in the NHS and more broadly, to convey how decisions can be made health enhancing and environmentally sustainable. A further challenge is that of macro-economics, socioeconomic inequality and the structure of the welfare state – how changes in welfare, employment and taxation policy have immediate and longer-term implications for public health. ~
considering a placement in Scottish government?
St Andrewâ€™s House. Home of the Public Health Department of the Scottish Government. Source Flickr. Scottish Government
Bute House, Residence of the First Minister of Scotland. Source Flickr, Scottish Government
INTERVIEW WITH … JANINE THOULASS? By Josie Murray
What learning outcomes did you achieve?
Having heard that Janine had just ﬁnished an exiting post in Scottish Government, I caught up with her over coﬀee in Waverley Gate, NHS Lothian’s Headquarters, and home to my Public Health department.
It was a really useful attachment to do at the very end of training because a lot of the learning outcomes met were the ones which were quite diﬃcult to reach elsewhere. Things like negotiating, policy development and chairing meetings. There were a lot of really exciting opportunities.
You have been on placement in the Scottish Government, how did this come about? The person in the post was going on placement for three months, and one of the other SpRs proposed that we job share as we both work part time. We got to do the post, as an ‘acting up’ opportunity.
One opportunity was an Ebola training event. It was run by the army and they have a mock facility set up. We visited and had training for a day and it was really interesting. And going to national conferences and national meetings, and being exposed to things that you wouldn't ordinarily get the chance to do.
What job was it that you were doing? Acting SMO [Senior Medical Oﬃcer], we split it between the two of us, so Fatim did some bits and I did other aspects.
What did your responsibilities entail? The main area that I covered was tuberculosis. I dealt with any work that came in to do with TB, but because it was a job share we also did a bit of cross cover. If something came in on the day you were working that wasn’t necessarily your topic area but needed to be dealt with on that day, then you dealt with it. The work could be a huge range of things. It can be to do with national documents that are being developed, work in response to medicines, or TB cases. You would quite often ﬁnd yourself working with HPS [Health Protection Scotland] or people from the health boards.
What would a ‘normal’ day entail for you in this role? There wasn’t really a normal day! That was one of the things that was really good about it. It was really varied in terms of what you did. I don’t think I was even in the oﬃce for the ﬁrst two weeks or so because I was mainly at meetings and conferences, so I was out of the oﬃce a lot. The days that you were in oﬃce would usually just be catching up with emails and preparing for the next meeting and things. No two days were the same. Pictures. Left: TB. Source: Stop TB UK Above: Source: Ebola Training. DFID Flickr, Image: Graham Harrison/MOD Licence: OGL Page 13
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What were some of the highlights for you? For me the highlight was seeing the other side of the TB work for the other two days. During this placement I worked on TB locally in the health board and TB centrally at the Government. Being able to understand why things were being done the way they were made a huge diﬀerence to how I then was able to work locally. Not the speciﬁcs of it, but just the general understanding of what the motivation and central drivers behind the work. This was the highlight for me because it made me reﬂect on how I would adapt any future healthboard work to think about what the barriers may be in terms of wanting to take things forward. I think it gives you a greater appreciation of that having worked at the government.
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I think that one of the things that was diﬃcult about this job was that it was split. It was only part time and it was a short period of time so it almost felt like I had only just got insight into how it was working. I would probably say to do it for a longer time period.
What have been the most valuable learning points? It felt that it was a really good time to do it because it was right at the end of training. It’s a really good way of taking on more responsibility and preparing to be a consultant. Although I'm not going straight to a consultant post I think it would make me a lot happier about going to a consultant post having done it now.
How do you think this placement helped you in your career development? I think it was useful because I went to an interview for my next job towards the end of this placement. I thought it was really useful having been in a position where I had been a little more visible and had been in a few more stressful situations . The interview felt a lot more comfortable and also it gave me something really interesting to talk about.
What were the main challenges in this post? Understanding the dynamics of how things work at government and how government relates to other national bodies and health boards can be quite diﬃcult. I felt very aware of wanting to make sure that I didn’t say the wrong thing or inadvertently impact negatively on relationships. You’re very aware that you haven’t been there for very long and that you are relatively junior. Yet you’re dealing with people who are actually relatively senior and who know an awful lot more about a lot of the things than you do .
What would you say to anyone considering a placement in Scottish government? Go for it! It was a really good experience. I would organise it well ahead of time. Think carefully about what you want to get out of it. I would highly recommend it to anybody. I have heard the most stressful times of your career is becoming a consultant and so if there is anything you can do to help yourself prepare for it then I think do it, grab it with both hands. ~
Janine gained an EPIET fellowship post in Berlin. We wish her well in her new job!
Scottish Public Health Review Destination Unknown: Notes from the Journey By Esther Curnock The obligatory plenary from the Minister for Public Health at the annual faculty gathering in Scotland doesn’t usually oﬀer too much in the way of surprises, but the speech given in Aviemore last November quickly became the main talking point for the rest of the conference. Following the announcement that the Scottish Government had established an expert group to conduct a review of public health people soon started speculating as to what the direction of travel might be. As a registrar group it was clear that the implications could be signiﬁcant, both for training and future post-CCT career opportunities. Compared to England and Wales, delivery of the public health function in Scotland has remained remarkably stable over recent years. Generally speaking the SNPled government takes every opportunity that comes their way to reinforce their political distinctiveness from Westminster, and even more so when it comes to the direction the NHS has taken since Andrew Lansley’s reforms.
However, minutes from the ﬁrst meeting of the review group along with other parliamentary debates from that period reveal the (then) Cabinet Secretary for Health was keen to explore closer integration with local authorities. Moving towards the ‘English model’ had seemed unlikely to many people, but now suddenly seemed a plausible potential outcome for public health. This all took place a couple of months after the independence referendum; with the Smith Commission already underfoot and politicians starting to gear up toward the Westminster 2015 election, as well as Scottish Parliament elections looming in 2016, it was a wake-up call that some fairly radical changes could be on the horizon for the Scottish public sector. With a clear stake in the outcome of the review, it seemed imperative for the Scottish registrar group to proactively engage and request a seat at the table. A letter to the Chair of the review articulated our position and was met favourably. However, our request for review group membership was turned down; membership had already been established, and they were facing pressure from multiple parties voicing a claim for representation (only one consultant was on the group and no current DPH had been invited). As we moved into the start of a new year we organised a training meeting to brainstorm responses to the engagement consultation paper questions, and established a small writing group to gather and formulate our ideas. Weekly email updates were used at this stage to try to ensure everyone was kept in the loop within the registrar group, and that all the
Photo: Call for Abstracts, FPH Scotland conference 2014 ‘Health in a Changing Scotland—the balls in our court’
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snippets of information that came our way about where things might be heading were being shared between us. Following our submission representatives of our group were invited to meet with the Chair and government policy lead shortly before Easter. On reﬂection preparation for this meeting could have been better; it would have been useful to apply some of the principles from media training and ensure we had pre-agreed a handful of clear-cut key messages to communicate.
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What lessons have I learnt from this journey thus far? I’ve discovered that there is a wide spectrum of opinions within the public health workforce as to what level of engagement is appropriate or wise in this type of process, with some people even warning individuals could be seen as ‘tainted’ if they got too involved. I’ve realised that with a bit of imagination multiple avenues can be used to open doors to try to inﬂuence political processes, even if they all seem closed initially. As always, information sharing and trying to ensure communication was clear and timely was key to maximising all the opportunities we had as a registrar group. I’ve certainly gained greater insight into the relationship between elected members, the civil service and the role of short-life expert working groups than I had this time last year, but I also have to admit that in other ways the decision-making process seems more than ever to be a ‘black-box’.
Wordcloud: StR group vision for Public Health
Nonetheless, one tangible outcome from the meeting was that we were invited to write a ‘vision for public health’ to inform the deliberations of the review. By this point I had also started a part-time attachment at the Scottish Government to further contribute to the review by conducting a review of existing research literature on the themes of public health leadership, partnership working, and workforce development; these topics were derived directly from the terms of reference of the review group. This role enabled me to observe some of the internal politics of St Andrew’s House as well as giving me the opportunity to participate in one of the meetings of the review group.
I’ve also found that navigating through multiple changing political agendas is complex; the review is evidently being conducted in the context of wider conversations around the distribution of power and resources in Scotland, (shared services, community empowerment, public sector reform and localism for example), but the ﬂows of inﬂuence between those diﬀerent agendas are often opaque, and some are clearly in tension with one another.
It is fair to say there have been several unanticipated twists and turns on the journey, and the political landscape continues to shift. Where are we headed? All the signs point toward change, but beyond that, I think at this stage the destination remains unknown. ~ ESTHER CURNOCK is currently co-chair of the Scottish Registrars group and is an ST4 having completed a 2 year Out -ofprogramme post with the MRC
Spot the differences? Scottish Parliament
Scotland England Wales Northern Ireland
How many chambers?
Two chambers (House of Commons and House of Lords)
How many members?
129 Members of the Scottish Parliament (MSPs)
650 Members of Parliament (MPs) in the House of Commons 790 Members of the House of Lords, collectively known as peers
How many members 129 MSPs representing Scots on represent Scotland? devolved matters
59 MPs representing Scots on reserved matters (Peers work for the whole of the UK)
Who does it scrutinise?
The Scottish Government and its agencies
The UK Government
How are members elected?
MPs are elected using the ďŹ rst-past73 constituency MSPs are elected by the the-post-system ďŹ rst-past-the-post-system Peers are not currently elected, but are 56 regional MSPs are elected by appointed by Her Majesty The Queen proportional representation on the advice of the Prime Minister
Elections are normally every 4 years. Elections are every 5 years The next Scottish election is scheduled When are elections? The next UK Parliament election is in for 2016 (5 years since last election) to May 2015 avoid a clash with the UK Parliament election which was held in 2015
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So how does it work? Scottish Parliament
Reserved matters. The UK can make laws on devolved matters but it generally doesnâ€™t
The Scottish Government Members of the Scottish Parliament Who proposes laws? Committees of the Scottish Parliament Private companies, individuals or groups
The UK Government Members of the House of Commons Members of the House of Lords Private Companies
Devolved or reserved?
Who examines the laws?
The House of Commons The Scottish Parliament The House of Lords Committees of the Scottish Parliament Committees
Who has the ďŹ nal say? MSPs
MPs Members of the House of Lords
Who implements the The Scottish Government laws?
The UK Government
These tables have been adapted from the Scottish Parliament website. Photos on page opposite: Scottish parliament. Source : Edinburgh Architects. Photographer Keith Hunter. Westminster Palace. No copyrights. Photos on this Page. Scottish Parliament. Source: Edinburgh Architects. Photographer: Adrian Welch. Westminster Colling Tower. Source: Flickr by The Duke of Waltham
’LEGAL HIGHS’: MY EXPERIENCES AND REFLECTIONS? By Emma Fletcher When I was considering what to do for my next training attachment last year a Consultant colleague approached me and asked if I wanted to do some work around ‘legal highs’. Aware of the emerging media coverage of the topic at the time and curious to ﬁnd out what all the fuss was about I eagerly accepted the opportunity. The plan was to conduct a needs assessment looking at the impact of ‘legal highs’ on the Tayside area with the aim of improving the help and support provided to people who take the substances or know others who do. Soon after starting the work I very quickly learned that the preferred term is new psychoactive substances (NPS), not ‘legal highs’. ‘Legal’ implies a level of safety and legitimacy with the substances that is simply not present – there is no quality control with NPS and many contain a variety of pharmacological agents and illegal substances. However, we were in a bit of a quandary when it came to advertising the survey to the public. We did not want to be seen to be endorsing the term ‘legal highs’ but at the same time wanted suﬃcient publicity for the study to engage the public and achieve a high response rate. Eventually we settled on including both terms but this tussle has persisted whenever we are discussing our work in new arenas. Reﬂection: original names are hard to shift, especially if catchy!
When it came to advertising the survey we were greatly helped by the substantial media interest in the topic at the time. In addition to radio and TV interviews, the local newspaper was happy to run a double-page spread to discuss NPS and promote the survey. Thankfully I had several media training sessions under my belt by this point and was supported by Consultant colleagues and NHS Tayside Comms but it was still a steep learning curve nonetheless! I stuck largely to a brief pre-prepared script of the points I wanted to convey and I was fortunate in that my ﬁrst exposure to media was a collaborative eﬀort and not adversarial. Reﬂection: if the prospect of interacting with media is daunting (like it was for me) start locally and take as many opportunities as possible with collaborative interviews – practice deﬁnitely makes the process easier! The ﬁnal report (accessible from www.nhstayside.scot.nhs.uk/OurServicesA-Z/ PublicHealth/PROD_213564/index.htm) highlighted the potential public health impact of NPS and made recommendations to improve the way in which people who take NPS, their friends, families and professionals working in the ﬁeld are supported.
We distributed the needs assessment to local partners and released a proactive press statement. That was ﬁne, I was getting used to the media interviews somewhat although I’m not sure they will ever be an entirely comfortable process for me!
Images. Above left: Postcard distributed to public for survey engagement. Above right: Front cover of needs assessment
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However, I was not expecting the next development…. In addition to the media interest, there started to be signiﬁcant political interest in the work we had done. My co-authors and I were invited to attend the Scottish Parliament to watch the work presented and discussed in a members’ debate. Following the debate we were also invited to meet the Member of Scottish Parliament who tabled the session.
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Questions started. Should we go? We wanted the work to be promoted and discussed but did not want it to be politically aﬃliated to one particular party. Would we be seen as endorsing the MSP’s political views if we met with them? Should we accept hospitality?! What about photos??! For most of these we were able to consider our approach proactively but it did highlight to me the lack of awareness I had with regards to political processes and engagement with politics, politicians in particular. This is in stark contrast to media interactions, for which we receive greater training and I am much more aware of useful tips and structures to handle these. Overall reﬂection: having a political awareness is important; knowing about the public health impact of ‘legal highs’ is too! ~ EMMA (pictured below) IS AN ST4 REGISTRAR IN SCOTLAND, AND IS OUR NEW CURRICULUM CHAMPION AND PORTFOLIO CHAMPION
Images Left: Newspaper clippings of the media coverage of Emma’s work: (From left to right) Perthshire advertiser, Arbroath Herald, Courier.
LEGISLATION and Public Health A Journey through History! By Jenny Wares Given the pivotal nature of the wider determinants it is often interventions at a national policy and legislative level which have the greatest impact on our health and wellbeing. A notable recent example is the smoking ban in enclosed public places and workplaces which has been in place in Scotland since 2006 with evaluations demonstrating beneﬁcial outcomes in areas where compliance is high. Having said this, the value of policy and legislation is not new as illustrated by the timeline below which takes a step through time looking at some of the key public health measures. The timeline is adapted from ‘A Chronology of State Medicine, Public Health, Welfare and Related Services in Britain 1066-1999’, compiled by Professor Michael Warren, and illustrates the wide-ranging challenges which face Public Health and the diversity of interventions required to address them. The full chronology includes key parliamentary acts, reports of royal commissions and other publications and events that have been the basis for reducing inequalities and addressing factors which have been contributory to ill-health. It begins in 1066 following structural changes to the government at that time and ends in 1999 with the recreation of the Scottish Parliament and the creation of the Welsh Assembly. The ﬁrst public health intervention by government concerned the repair of sewers and removal of nuisances in 1225... Photo Dr Who. Source: Play Buzz. By: The Empress. Spiral Clock by Timothy A Pychyl, Source Psychology Today.
TIMELINE OF PH LEGISLATION
c.1225 Acts passed dealing with the repair of sewers and control of nuisances 1281 Pigs were prohibited from wandering in the streets by City of London Regulation 1297 City of London Regulation required every man to keep the front of his own tenement. clean More sophisticated measures were introduced over time with regulation in 1309 prohibiting the casting of waste into the streets of London and acknowledging that this should be removed from the city. The need to raise revenue was increasingly recognised with the ﬁrst Poll Tax introduced in 1377. This was imposed on all those aged over 14 years of age at one groat (four pence) per person. The need for society to support its most vulnerable members was beginning to be acknowledged with the development of measures which paved the way for the subsequent Poor Laws. However, until their implementation in the 16th century, charity was the principal means of support for older people and those with disabilities.
1388 The Statute of Cambridge (‘Poor Law’) concerning Labourers, Servants and Beggars strengthened the powers of the justices of the peace; distinguished between ‘sturdy beggars’ capable of work and ‘impotent beggars’ incapacitated by age or infirmity; forbade servants to move out of their ‘hundred’ without legal authority; and made each ‘hundred’ responsible for housing and keeping its own paupers, but made no special provision for maintaining the sick poor. Over time, more formal mechanisms were introduced with the development of the Poor Law Act which stated that money should be collected on a weekly basis and distributed to the poorest within society. Those refusing to give voluntarily could be imprisoned following sustained refusal. The Poor Law Act was consolidated in 1601. People were cared for in establishments based on their parish of residency and public health institutions. Further attempts to reduce inequality were enacted in 1589 with the implementation of a (Planning) Act requiring cottages to be built with accompanying land in order to prevent the over-population of villages with limited employment opportunities and thus reduce rural poverty. Health hazards were increasingly recognised as illustrated by the development of controls on alcohol and the publication of the ‘Counterblaste to Tobacco’ in 1604 by James I in which smoking was described as ‘a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs’. By the beginning of the 18th century the majority of the estimated 5.5 million population was living in the south of England, largely in hamlets and villages. Housing in urban areas was overcrowded, there were still no sanitary systems in place and child mortality was high. Over the course of the century, however, transport links improved, industry began to develop and towns and hospitals were built. Increasing industrialisation was accompanied by measures aimed at reducing the impact of occupation on health although early measures were extremely primitive in comparison with current legislation.
TIMELINE OF PH LEGISLATION 1751 ‘Gin’ Act for ‘additional Duty upon Spirituous Liquors … and the more effectually restraining the Retailing of distilled Spirituous Liquors’; suppressed about 1,700 gin shops in London. Income tax was introduced at the turn of the century at a rate of two pence in the pound for those with incomes of more than £60 a year, rising to two shillings in the pound on incomes of more than £200 a year. The burgeoning population highlighted the need to better enumerate and understand the composition of the population and the ﬁrst census of the population of Great Britain was undertaken in 1801.
1742 Aberdeen Infirmary (later Royal) opened with six beds. In contrast, the current Aberdeen Royal Infirmary sits on a 50 hectare site and has approximately 900 beds. 1749 Stage coach service between Edinburgh and Glasgow began, taking 12 hours each way. Although the commute can still be a bit of a nightmare, the journey time between the two is now just less than an hour. 1788 Act for the Better Regulation of Chimney Sweepers and their Apprentices intended to alleviate ‘the misery of the said boys’. Apprentices had to be at least 8 years old and each sweeper was limited to six apprentices.
Communicable disease understanding increased as illustrated by the innovation of vaccination for the prevention of disease. Interestingly, and similar to some views held presently, there was opposition from antivaccination movements and those who deemed vaccination and other public health measures to oppress civil liberties and represented interference from the state.
1801 The first census of the population of Great Britain was carried out by a house-to-house enquiry together with returns of baptisms and burials between 1700 and 1800, and marriages between 1754 and 1800 as supplied by the clergy. The details included the number of inhabited and uninhabited houses, the number of families occupying the former, the number of persons of each sex, and the numbers of people employed in agriculture, trade, manufacture or handicrafts. The enumerators in England and Wales were the overseers of the poor, local clergy or other substantial householders; in Scotland they were the schoolmasters. The local returns were statistical summaries only, made in a prescribed form and attested before the justices of the peace. The population in England and Wales was counted as 8.9 million, but if allowance is made for under-recording the total was estimated at 9.2 million.
TIMELINE OF PH LEGISLATION 1808 National Vaccination Board established under the auspices of the Royal College of Physicians of London to encourage vaccination. Parliament subscribed £2000 per year.
The importance of the urban environment to health and wellbeing was increasingly recognised as illustrated by the establishment of the Health of the Towns Association in 1844 in order to disseminate information regarding the implications of insanitary conditions and to ‘substitute health for disease, cleanliness for ﬁlth, order for disorder, economy for waste, prevention for palliation, justice for charity, enlightened self-interest for ignorant selﬁshness and to bring to the poorest and meanest – Air, Water, Light’. The ﬁnal report led to the Public Health Act 1848. The cholera epidemic reached its peak in the autumn of 1849 with reports of 3,183 deaths in London. Signiﬁcant sanitation reforms followed with the passing of the Sewerage Utilisation Act and the subsequent Sanitary Act which guided the provision of sewage disposal and water supplies. The subsequent Public Health (Water) Act ensured that all occupied houses had a suﬃcient supply of potable water within a reasonable distance.
1855 Dr John Snow’s epidemiological investigations, suggesting that water was the major mode of cholera transmission, were published in the book ‘On the Communication of Cholera’. The importance of education was recognised and the ﬁrst major education act was passed in 1870 which attempted to provide elementary education for all children. Alcohol licensing was introduced in 1872 limiting the number of premises which sold alcohol and their opening hours. 1897, Queen Victoria’s Diamond Jubilee, saw an editorial in ‘Public Health’ which stated, ‘of all the achievements of the Victorian Era ... history will ﬁnd none worthier of record than the eﬀorts made to ameliorate the lives of the poor, to curb the ravages of disease, and to secure for all pure air, food, and water, all of which are connotated by the term sanitation’. Motorised transport became increasingly popular allowing more rapid transport of goods and people across the UK although the compulsory use of seatbelts was not introduced until the 1980’s.
TIMELINE OF PH LEGISLATION 1903 Motor Car Act raised the speed limit to 20 miles per hour; required numbering, registering and lighting of all cars; and introduced an offence of reckless driving. A Bill to introduce driving tests and penalties for driving under the influence of alcohol was rejected. 1925 Order given for the painting of white lines on roads to try to reduce traffic accidents. 1930 Road Traffic Act defined driving offences and set out the law regarding accidents, insurance, use of the highway, erection of traffic signs and the introduction of speed limits. 1933 Thirty miles per hour speed limit introduced in built-up areas.
The National Health Service Act of 1946 was devised in order to provide healthcare free at the point of delivery and began in the UK on 5th July 1948. Despite the publication of the ‘Counterblaste to Tobacco’ in 1604 the ﬁrst report on the link between cigarette smoking and lung cancer was published by Doll and Hill in 1950. Cigarette advertising was subsequently banned on TV in 1965. Outdoor air quality was also poor with the Great Smog of London in 1952 resulting in about 4000 deaths, leading to new legislation on smoke pollution and the development of the Clean Air Act.
Although this is just a very brief jaunt through history as it relates to public health and politics, hopefully it illustrates the utility of policy and legislation in tackling challenges facing public health and opportunities for the future. ~
Photographs used in timeline (in order of appearance): No pigs allowed. By Ryan McLaughlin. Megabus James VI and I. james 1of England by Daniel Mytens. Gin Lane 2d version of William Hogarth's original. No copyright. Aberdeen Royal Inﬁrmary Postmark by Geoﬀ Childs from GB Cover Collector. Poor laws 1834. Source: The National Archive. Cholera Map by John Snow from J Snow On The Note of Cholera 1885. Public Domain. Smoking and Health, 1962 source: Royal College of Physicians www.rcplondon.ac.uk. Photo:s below by Jenny Wares.
PuBlic Health & POLITICS A u g u s t
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