Professor Kevin Fenton: Healthy people are productive people

Matthew Taylor

Hello and welcome to Health on the Line. We're a few weeks into a new government. A government that has pledged to take action on public health, tackling the biggest killers and supporting people to live longer, healthier lives. We've already seen some encouraging signals in the King's Speech. But there's a lot further to go, with bold action needed across multiple fronts. 

At the moment, there's a shocking 18-year difference in healthy life expectancy between the most deprived and the most affluent communities. It begs the question, what more should we do when it comes to public health? 

Halving the healthy life-expectancy gap, which is what Labour's now committed to, and taking a proactive approach to tackling inequalities must surely be the centrepiece of health policy over the next decade. 

There were, of course, tragic echoes of this in the covid inquiry's inaugural report, which called on the government to take proper account of inequalities and vulnerabilities when planning for public health emergencies. We used to talk a lot, didn't we, about making sure that we learnt the lessons of covid, but perhaps we can return to that idea and think once again about the legacies of the pandemic and how we turn them into meaningful developments in public health practice. 

To consider these issues and more, I couldn't be joined by a better person than Professor Kevin Fenton. Kevin's a medical doctor, academic, public health specialist, and infectious disease epidemiologist. He's played a vital role in shaping public health in the UK and internationally. He's president of the Faculty of Public Health, regional director for London and the Office of Health Improvement and Disparities, and statutory public health advisor to the mayor of London and the Greater London Authority. 

Kevin, welcome to Health on the Line.

Kevin Fenton

Thank you. It's really great to be here. 

Matthew Taylor

Now, Kevin, I'm going to ask you a couple of really basic questions just to start off because, you know, our listeners come from across the health and care system and beyond. Public health, it's used in different contexts, isn't it, as a phrase? 

Sometimes we talk about it as a general aspect of society, the public health of society. Sometimes we talk about it as a particular domain of activity, you what the directors of public health and local government do. Sometimes we talk about it as a kind of specialty. 

How do you understand the concept of public health? And do you think we do too often get confused by what we really mean by it? 

Kevin Fenton

So a great question to start off on. And for me, as a public health practitioner, I view public health as a discipline, one of the family of disciplines within medicine and health. And it really describes the organised efforts of society to improve health and to tackle inequalities. 

And the reason it's the organised efforts of society is that it goes beyond health services and it involves what government can do, what businesses can do, what members of the public can do. What we all can do to improve health and address inequalities. 

And it also goes beyond thinking that somehow health is a responsibility of other people. It's a more inclusive definition. It's a definition that allows for partnership and engagement across a wide range of partners. 

Now, what is important is that the way public health is implemented and conceptualised will vary upon society that you're working in, the assets that you have available, the ways in which community engagement and mobilisation is valued by your societies. So the way we practice public health may change from location to location, from country to country, but the core components of organised efforts of society remain the same. 

Matthew Taylor

And Kevin, how do we understand the relationship between public health and what the NHS does, in essence, what we often call health policy? 

Kevin Fenton

So the NHS would be one of those core partners involved in creating and improving the health of the public or public's health. And that is where we see the NHS and the role of NHS being so critical. And in fact, there is a subspecialty of public health practice here in the UK, which we term ‘healthcare public health’, which really describes the specialist practice of public health practitioners who work within the NHS, who have a vital role to play in helping the NHS to improve quality, to commission better quality clinical care services, which looks at health inequalities in the services provided by the NHS and are able to help them to mitigate those inequalities and can help the NHS on a range of health promoting policies from workplace-related policies to the role that the NHS plays in communities as anchor institutions. 

In other words, public health practitioners have a valid role to play in the NHS, in local government, in national agencies, as well as in the Department of Health and Social Care because we bring that broader thinking around health, what drives health, what promotes health and how to tackle inequalities. And we connect systems by virtue of working in so many different parts of the broader health and care system. 

Matthew Taylor

What I find fascinating, Kevin, is that when we talk about public health, we describe a range of things from those things which public health professionals can affect directly. They might be able to directly put in place a strategy for tackling infectious diseases. They might be able to put in place at a local government level directly policies to, I don't know, make food outlets safer or to reduce retail harms or whatever it might be. 

But then it extends to policies which go massively beyond public health, around child poverty and housing areas where actually public health professionals themselves have relatively little influence. Is this kind of one of the challenges with us getting our head around the kind of sense of agency that exists within public health? 

Kevin Fenton

I wouldn't say so, Matthew. I mean, if you use the comparable terms, child health or mental health, all of these are terms for use to embody a much more holistic, much more inclusive approach to improving health and reducing inequalities in a particular domain. And as you say, child health can include everything from the paediatric services straight through to oral health, food, nutrition, and so forth. 

The reality is, in the space of public health, we're talking about a holistic approach to improving health and tackling inequalities operated by a range of partners. We know that the pillars of public health practice are, as I've mentioned, healthcare public health, the work that we do to promote health, the work that we do to secure health and to health protection and health security. Those are core pillars of public health practice.

And then of course we have data and evidence which are core to everything we do. 

So I think that where we may have a misunderstanding of public health, it's both incumbent upon those of us working in public health practice, but also partners to both make the definition and the ways in which we work real to members of the public and policymakers and to be specific about what components of public health we're speaking about.

Now, Matthew, in the pandemic, you will agree that everybody across the country thought what public health was, whether it was the CMO on TV with the Prime Minister speaking about COVID-19, or whether it was myself and many other practitioners around the country speaking about vaccinations, engaging communities, protecting family members and so forth. That brought the concept of public health alive to so many members of the public and provided a deeper understanding of what we do to secure health within our communities. And that, think, is what we perhaps need to do more of moving forward, rather than getting into the debate that the health and what creates health is at the NHS, which is often where the conversation ends rather than begins. 

Matthew Taylor

I absolutely get that. Indeed, of the, actually one of the early things, Kevin, I did in this role at the Confed was to establish a forum to bring together directors of public health in local government with people leading on public health in integrated care systems, because I wanted to overcome that kind of cultural institutional divide between people looking at this from within and from beyond their health service. 

Now that creation of ICSs is one of the things that has kind of changed in the public health landscape over the recent years. I suspect covid would be another one. Maybe Black Lives Matter is a moment of real focus on race and inequality. Would those be the kind of three things that you say have been, would say been the most important changes in the way we think about public health or other ones across your career, Kevin, that you think have been very significant? 

Kevin Fenton

Absolutely. In a more recent time period, I would point to the ones that you've just mentioned. But there many other influences which are driving both current public health practice and the future of public health as well.

Now for my own practice – so I've been working as a public health specialist now for nearly three decades. My early engagement in public health was because of the HIV AIDS pandemic, right at the beginning of the 80s and 90s, which shaped my understanding of global pandemics, which influenced my choice as a medical student to do epidemiology and public health and the values of equity, of social justice, of engaging communities and advocacy and participatory research have been part of my public health practice in the sense that HIV AIDS has changed clinical practice over the past four decades. 

So we do have these points where we have influences and these influences can also include the political influences as well as governments change and governments and policymakers provide new opportunities for us to think about public health practice differently. 

For example, governments may be more open to health being not only the responsibility of the Department of Health, but working across other government departments to generate health and have wellbeing at the centre of government policies. 

And of course, we also have external threats which are changing public health practice as well. So the climate crisis is forcing us not only to think of public health and moving beyond thinking about the drivers of health in terms of poverty, access to education and housing, but really thinking of climate change as the biggest existential health crisis that we're facing and how we then use that to shape public health policy and programmes in new and exciting ways. 

So yes, I think covid, the experiences that we've had with Black Lives Matter and the focus on equity and the post-covid recovery period are certainly driving changes that we're seeing in public health.

But bear in mind that there are always going to be influences on policy and practice in this space, very similar to how clinical medicine continues to shape and evolve as well. 

Matthew Taylor

And you've spoken about covid. We've seen the publication of the Covid Inquiry's first report. What do you think are the most important takeaways from that report? 

Kevin Fenton

We, first of all, welcome in the Faculty of Public Health the first reporter. We're still going through the report in great detail to understand in depth many of the key recommendations. 

But we were very pleased to see some of our key recommendations in the inquiry being amplified in the recommendations. These include the importance of really investing in preparedness and planning and doing so across multiple agencies and government, the importance of regular inclusive exercises, the importance of having equity and understanding inequalities as a key theme throughout planning, preparedness, and the response to all emergencies, including as well the importance of investing in and supporting the workforce for pandemic planning and preparedness. 

There are a number of core themes that we had identified in the faculty as areas for improvement moving forward. And the key challenge that we will see now will be how are these recommendations which have been made going to be enacted? What is the process both within government and outside of government to reflect on these recommendations to accept the recommendations which are most relevant, but most importantly, Matthew, to demonstrate changes in behaviours and investments that can ensure much more robust infrastructure for emergency planning and preparedness. 

That is what we would like to see, as the faculty, arising from this, which are demonstrable and measurable changes in the way we do preparedness that demonstrates legacies from the pandemic. 

Matthew Taylor

Well, as you say, Kevin, it's all about implementation, isn't it? 

So let's turn to a couple of opportunities that now exist with a new government, with its commitment to a health mission, which goes much wider than the NHS. And there's something that we, indeed, in the Confed have been calling for some time.

Let's look at two very different angles of this. The first is around kind of harms. Now, I'm sure that you, like I, and like us at the Confed welcome the fact that the government is reintroducing the smoking and vapes bill, but also that it is talking about going further than that in relation to trying to protect, particularly children, from junk food, advertising, looking at energy drinks, building perhaps on the success of the sugar tax.

Are you hopeful that we will see a more concerted attempt to harm because the previous government often seemed rather ambivalent about this, particularly when it involved regulation?

Kevin Fenton

We're very hopeful in the faculty. And I the King's speech really provided a cause for optimism at this very early stage of the new administration. And in part, because this takes us back to where we started the conversation about public health being the organised efforts of society. And there things that only government can do and only government can pass policies, legislation and regulation that can have such a significant impact on reshaping both the commercial landscape, but also reshaping the environments within which we live, work and play so that health is promoted and supported. 

And the policy recommendations and the bill recommendations which you've mentioned have been fundamental asks from the public health community and the wider health community as well, including the NHS, to enable all children and all of us to be able to live longer and healthier lives and to create the environments for that to occur. 

And by doing so, to reduce the pressure on the NHS and therefore costs to the economy of the long-term plan. 

We know, Matthew, that issues such as alcohol and smoking and obesity and the declines in physical activity are major drivers of premature morbidity. In other words, people develop pain, chronic diseases early on in their life course. It's a meta driver of the inequalities we see in life expectancy and healthy life expectancy. 

And we're very concerned in public health because more people are developing multiple chronic conditions earlier in their life course. Again, largely driven by these factors such as poor diet, the excessive use of alcohol, smoking et cetera, and poor physical activity. 

So by government putting in place policies, regulations, and legislation that enables us to support individuals and communities to be healthy and to live healthier lives, that is one of the critical steps that needs to be taken on our journey to getting ourselves back on track. And this is particularly important as we're talking about economic productivity and thinking about work and health and how we enable people to be healthier and be more economically productive within the workforce. We have got to address these issues. 

Matthew Taylor

And how do we get the balance right then, Kevin? So when it comes to harms, you we have an account which emphasises the importance of government protecting us from harms. We can have an account which is individualistic about the need for individuals themselves to take action, not to drink too much or smoke too much or to eat better or to take exercise.

Or we can take a kind of social lens on this, which says, well, look, there are clear correlations between poorer people having worse diets, smoking more, more likely to become addicted to substances. 

How do we get the balance of that kind of regulatory individualistic and social way of understanding these issues? 

Kevin Fenton

A great question. I think that is what all of us in public health, working in public health, grapple with on a day-to-day basis. 

You know, the reality is that all three of those drivers, may be important for different topics at different phases. So for example, we know that the public has really good appetite for and is calling for stronger action on vapes, on reduction in risk from passive smoking, and therefore government may be able to move much further along the policy landscape and scope in terms of critical actions to address this. 

We know that most people and most members of the public want children to be healthier, to be more active and to reduce exposure of kids to high fat, salt, sugary foods. That's documented, it's consistent, and this is an opportunity for where government can do more. 

So we know that for some issues and some challenges where the public appetite exists, government can certainly go further. 

However, there are some areas where perhaps because of lack of knowledge and awareness and the public lack of engagement, the public may not be there and that's a critical role then for government to play a role in both drawing a detention to the challenges and to help the public to move in the direction that it needs to either by legislation policies which nudge or which create an opportunity for the public to make better choices. 

And I would say that perhaps alcohol policy is perhaps in this space where oftentimes government feels that the public is less supportive for alcohol legislation and action on alcohol and therefore may be more reticent about putting in place major policy actions. 

But we now have very good examples from Scotland, from Wales and Northern Ireland about policy interventions for alcohol which work, which may in time allow the UK government to move more deliberately in this space. Again, getting that balance right between what the public thinks is important, what the evidence says we should do, and the policy and the legislative opportunities which exist. 

So it varies and it really requires you to be actively engaging with the public, actively looking at the evidence, and of course, working with your partners in public health and in the health service on which policies to implement, when and how to do so. 

Matthew Taylor

That's fascinating, Kevin. And it is a question of prioritisation. 

I often say to young policy people that if they had the chance, they should listen to a wonderful Radio 4 series called Whodunnit?, presented by Michael Blastland, which was about why it was that teenage pregnancy rates fell by 50 per cent in the UK. It was unheralded, nobody expected it to happen. And I don’t know if you've heard that series, but he comes to the conclusion that it's a kind of unknowable combination of long-term contraception, government strategy to educate young people in particular, social media – so people spent less time hanging out in bus shelters and more time on Facebook. And he even talks about the effect of character called Vicky Pollard in Little Britain who kind of made having children as a teenager kind of seem a bit unfashionable, made it something that people laughed at. It's an odd mixture of all these things. 

So, when we want to tackle something, let's say obesity, we need to be kind of attacking it on multiple fronts to really make a difference. 

Kevin Fenton

Absolutely. And I'm so glad you used that example of teenage pregnancy because actually as a young public health doctor, I’m gritting my teeth in public health practice, my early area of specialisation was HIV sex and reproductive health. So I did a lot of work in the nineties and noughties on teenage pregnancy as well. And it was just wonderful to see the progress that had been made. And as you say, it's a combination of multi-level interventions. So national, regional, local activity coordinated around a national plan, well-resourced for implementation, great metrics to be able to measure our progress and to hold each other to account for progress and also celebrating the successes as we went along, in addition to many of the other social factors which you've mentioned. 

And Matthew, we can look back, and this is really critical, that the amount of times people say to me that, know, oh well public health take so long to reap the benefits of the investment. And I now push back at that because I have seen the tremendous progress we've made, whether in reducing HIV incidence in our country, teenage pregnancy, the smoking legislation that we're seeing, where it's the cumulation of interventions over time based on the best evidence, but implemented at scale, which has enabled us to be discussing elimination of tobacco smoking by 2030, bringing end of HIV transmission in England by 2030. 

These are public health wins and public health success stories that we tend to somehow diminish because we think it takes so long to achieve when actually what we're seeing are the net impacts of that cumulative intervention over time while we're gaining the current benefits of those prevention activities. 

So great example, and I think it really brings to the fore of what's necessary for success in public health. Strategy, coordination, implementation, resourcing but also accountability through your metrics as well and bringing the public with you on that journey. 

Matthew Taylor

Thanks, Kevin. I think it's also, I think about avoiding false oppositions, false dichotomies. know, if we want to tackle obesity, there's a role for encouraging people to take more responsibility for, for example, you know, clinicians working with people who are at risk of type 2 diabetes to show to them how relatively quickly they can reverse or they can avoid that outcome. But it's also going to be, as we've said, around the kind of regulation of harmful food and drink. And yes, there may be a role for anti-obesity drugs within an overall strategy. 

Sometimes I think there are kind of false divides. People say, well, if you believe in using the anti-obesity drug, then that means you don't care about the... No, no, doesn't. When we want to solve the problem, the one thing I think I've learned from my long career in public policy is that to really address complex human problems, you do need multiple things that all kind of work together. They lock together and they turn the dial. 

Now, Kevin, I want to turn from the kind of specific to the very general, which is that I find it fascinating that the Labour government is now committed to halving the life expectancy gap between the poorest and the richest areas. 

You know, it's interesting, that there was a lot of speculation before the election and since around how realistic Labour's waiting list commitments might be or its commitment to return to constitutional standards. 

Not much conversation about how realistic this incredibly ambitious public health goal is. I mean, are you excited by the fact that we have a government committed to doing that? And do you get much sense that the government understands quite how challenging that would be? 

Kevin Fenton

So first of all, the faculty is excited about this. It is important that we have bold, ambitious targets, what we want to achieve in improving the public's health. This is of benefit, not just for the health of individuals, but it is fundamental to the government's mission of growth and economic productivity for the country. You cannot have a productive society if you don't have a healthy society. And we know that healthy life expectancy and the gaps, the inequalities in healthy life expectancy have gotten worse over the past decade. 

So this must be an area of focus and it must be an area of focus in order to achieve overarching goals of growth for the nation. 

Now, to do this will require a whole infrastructure building upon the conversation we just had that you don't have these bold ambitions without proper strategy, a fundamental change in how government works, for example, ensuring that there's cross-government accountability to the health mission, for example. That government takes and makes the big calls on policy, legislative and regulatory actions, which enables those implementing programmes at regional and local level to do a much better job of tackling healthy life expectancy. 

And wherever possible that that shift in where we spend our resources. So we move from acute and urgent care into prevention and early intervention as a core part of tackling many of these issues before they become problematic. 

All of those things, Matthew, become important if you are serious about tackling healthy life expectancy and reducing the gap. 

And so it's with that contingency that we're both excited about the ambition and we say, well, let's see how we will need to be organised, how we will work together, how we will ensure that we're keeping a laser-like focus on this. And I think public health practitioners across the country stand ready to work with the NHS, ICBs, businesses, and so forth in order to make this a reality. 

We have some great examples in London where I work, where we're doing things differently, fundamentally differently. Our approach to CVD prevention, for example, means that not only are we looking at what the NHS is doing, but really now beginning to build deeper inroads into our communities based on our lessons from covid, engaging businesses, engaging academic institutions to help us to tackle this major driver of inequality in health and life expectancy. But it requires us to do things differently. 

Matthew Taylor

Yes, it's absolutely right, Kevin. And I wonder whether there's a case for us trying to develop and we would really enjoy working with the faculty on this, a kind of campaign in civil society behind that government objective so that we can keep reminding government of what they're committed to and advising and supporting them in making progress on that. 

Now, Kevin, a final question. The government has talked a lot about the role of health in economic growth, and we welcome that, we welcome Wes Streeting's emphasis on the fact that if we have many, many people who have health and care issues that not being addressed, it has an impact not just on them and on the health service, but on the economy as well, and particularly the 900,000 additional people out of the workforce since before covid as a consequence of health and care reasons. 

But there's a different argument, which almost is the reverse of that. I'm currently reading the proofs of a new book by the Surrey academic, Tim Jackson, about the care economy. And I think what he argues eloquently in that is that there is a conflict between the idea that as a society what we want is health and a notion that what we want as a society is wealth. That in a sense we have to make some choices about what really matters to us and that shouldn't we as a society be saying ultimately the measure of progress in society is health and wellbeing rather than necessarily economic growth. 

And then link to this, Kevin, is the issue of mental health. We've talked throughout our conversation largely about physical health and the things that can contribute to improving physical health. But of course, we are seeing a huge growth in demand for mental health services and the issues that seem to determine people's mental health, issues like levels of kind of anxiety and pressure in society, the level of loneliness in our society. 

Well, these things are difficult to address unless we're able to have this kind of broader conversation about what a society that maximises health and wellbeing is like. 

Am I straying too far, Kevin, away from the basics of public health or is this part of the conversation we need to have? 

Kevin Fenton

No, Matthew, this is definitely the conversation we need to have. And in fact, in the Faculty of Public Health's strategic document published before the elections, we articulated in our vision for the public's health. 

This more expansive view of what needs to be done, where we situate and relocate public health away from public health departments and direct us back into how do we have health and wellbeing as a fundamental asset for society, that it becomes part of the economic productivity and a net contributor to growth within our society. 

And we have more honest conversations about the link between, especially, poverty and economic disadvantage and depredation and poor health outcomes and why both thinking of health and wealth, thinking of health and the economy at the same time are critical for us to make progress. 

And let me be absolutely clear, for me, my conceptualisation for health and our entire conversation today has been around physical and mental and social health because we cannot afford to create distinctions, false dichotomies between the physical, the mental and the social. When we know, as you say, Matthew, that the pressures, especially in the post-pandemic world of poor mental health for young people and for everyone across the life course, the social health concerns we have of social isolation, loneliness, coupled with the economic challenges that people are going through, means that more people are grappling with bigger issues now and perhaps are less resilient to deal with those issues than they were previously, thereby resulting in pressures that we're seeing both in terms of falling out of the workforce and requiring support from the NHS. 

So in summary, guess this more holistic framing is exactly where we need to be, but we have to make it tangible for policymakers. And in the faculty's vision for public health, we asked for four things:

1. Any new government, and therefore this new government, should promote policies and programs that are really geared towards improving the health and wellbeing of people and communities and addressing inequalities. And today we spoke about tobacco, alcohol, physical activity and other areas. 
2. We asked for the government to tackle poverty because we know that with rising child poverty, we're storing up problems, not just for the short and medium term, but for today. And so tackling poverty becomes the second ask and priority for new administration. 
3. And third, we have to continue to protect the nation from infectious diseases and prepare for threats and emergencies. And that's why the new report on the COVID-19 module one inquiry is so critical in helping us to understand where we need to focus for preparedness. 
4. And finally, the fourth ask is that we do invest in public health and prevention as assets for society and making health a priority for cross-government action exactly as we've been saying through this conversation, that a more holistic approach to improving health as an asset, which is valued not only by the Department of Health, but across government and driven through implementation, through missions, may well be the sort of structural game changer that we now need to do things differently to get different outcomes. 

Well, Kevin, look, it's been fascinating talking with you. There are huge challenges. Even as we hear every day of innovations in treatment for diseases, it is still the case that the things which are the social determinants of health, things that drive chronic illness, those factors are actually continuing to deteriorate. So there is so much to do but as I think our conversation is underlined, there is also enormous opportunity now, a government that seems to be committed to thinking about health in these broader terms.

Hopefully, it's going to be an exciting few years ahead for public health. 

Kevin, thanks so much for joining us on Health on the Line. 

Kevin Fenton

Thank you so much.