“When we did the original Health on the High Street in 2015 we didn’t know what we were going to find. We could guess, but we didn’t really know,” says Shirley Cramer, chief executive at the Royal Society for Public Health. “What we found was that the unhealthiest high streets in Britain were in the most disadvantaged areas. What does that tell you?” She answers her own question: “It tells you that the poorest people in the most disadvantaged areas have the worst environments. And we know that environment is really important for all the public health challenges we have.”
That report was about how high street businesses impact the health of the public. Pharmacies, along with libraries, dentists and opticians, leisure centres and pubs, were deemed good for health. Betting shops, payday lenders, tanning salons and fast food outlets weren’t.
The message of the 2018 follow up Health on the High Street: Running on Empty is different – its recommendations aim to inject life into high streets and make businesses more health promoting. “The key message is that we can do something about this,” Shirley says. “We’ve got inequalities all over the place, getting worse by the way, and we’ve got issues which can be changed with a bit of planning, a bit of strategy, a bit of comprehensive thinking. Local authorities, we know are trying their best, most of them, but with no money.”
Shirley admits that more money for local authorities does sit behind a number of the recommendations. “But really, it’s about making high streets liveable, happy places. Places people who are socially isolated want to go, you know? Somewhere you feel proud of, somewhere not full of chicken shops.”
What sets the top 10 apart – Edinburgh, Canterbury, Taunton – is some really good retail. “And the massive change since 2015 is empty shops. Devastation by online. We talk in the report about empty shops as opportunities. It’s about putting in that pop up, allowing a local creative to go in there for six months and use it to create a community space. Using business rates flexibly.”
At the heart of both reports in an analysis of the “healthiness” of different businesses on the high street – the ‘Richter scale of health’. Outlets were rated using four measures (each scored from +2 to -2): encouraging healthy lifestyle choices, promoting social interaction, allowing access to health care services or advice, and promoting mental wellbeing. Pharmacies rate as the equal third most healthy outlet along with health clubs, with a score of +5, behind leisure centres (+7) and dentists/opticians/GPs (+6). New positive entrants in 2018 included vape shops (+3) and café’s and coffee shops (+2). At the other end of the scale were high cost credit outlets (-4) and fast food (-2) with empty shops new in (-1). Total up the outlets and their scores, divide by the total number of outlets you get an overall score for a high street.
Shirley says the point was to highlight the issue and offer solutions for what might be done. “Some people thought it was a crude measure, but we’ve done it before.” I suggest the 2018 report was notable for calling out local authorities that had taken the 2015 version to heart and used local planning powers to ‘discourage’ further development of ‘unhealthy’ retail. Shirley agrees.
“There’s some great case studies; planning doesn’t cost them much. Stirling did a whole mapping; Portsmouth have done some good stuff,” she says. “The good news is the marked reduction in high street payday lenders – we really had a go at them in our first report.” Shirley chairs the End High Cost Credit Alliance with Michael Sheen the actor/social activist (“He’s fantastic”). “The other good news is on fixed odds betting terminals, and the acknowledgement we got around clustering of bookies, and of takeaways around schools and hospitals.” It prompted “a whole lot of ‘should we be letting this happen?’”
She knew the specific focus in the 2018 report on vape shops might be controversial. “On balance, we think they are a good thing,” Shirley says, adding that the view in the United States is very different. “They have evidence of gateway [vaping leading to smoking],” she says, “so public health in the States is anti e-cigarettes. Here the evidence is that there is no gateway so far, and that they are really good as a quit smoking tool. So, our position is that if you smoke, and only if you smoke, e-cigarettes are a good option, because they are a lot less harmful than tobacco. But e-cigarettes are not for non-smokers.
“Of course, we’ve got fewer smoking cessation programmes, and smoking still kills heavily so having an offering on the high street for smokers is a good thing, but we need to keep a close eye on the evidence. It concerns me it is so different on the two sides of the Atlantic.”
The first Health on the High Street report was noticed across the pond, notably by the Robert Wood Johnson Foundation, America’s largest philanthropic foundation dedicated solely to health. “They’ve done a lot on healthy cities and healthy environments, but they liked the retail bit, and they funded our 2018 report,” Shirley says. “They have also funded us to adapt it to an American model, working with the University of California in Los Angeles. It’s really complicated, of course, because American main street is a different kettle of fish, with gun shops, and marijuana places.” Shirley now sits on the Foundation’s global advisory board.
“It was very exciting to get an idea we had done in 2015 picked up like this, and it made us think a lot about how some of the other stuff we have done is useable in other places.” She cites the Society’s 2017 #StatusOfMind report as the one that has had the most media and “the most doable in other places”. The report brought out for the first time the views of young people about what social media was doing to them. “It’s amazing. It’s not a huge study, but it did catalyse thinking in this area. Now Matt Hancock wants guidance and that will be coming out in the Spring.”
Incidentally, it’s not entirely clear what Shirley thinks of the current Secretary of State for Health, especially since she describes herself and the RSPH as disruptors. “The NHS don’t know what to make of him, because he’s not interested in hospitals,” she says, before offering a sadly unprintable anecdote about Mr Hancock’s disruptive impact on the civil servants around him.
A new approach to teens and social media
The social media work started with the RSPH’s Young Health Champions (YHCs) programme. “They have a Level 2 qualification, so it’s the equivalent of a GCSE. They learn about health and health harms, and working with their peers,” Shirley says. “We’ve targeted our YHCs in the most deprived communities, and we were looking at social media, and found some alarming stuff. So we asked ourselves: ‘what do young people think about this’?”
For #StatusOfMind, 14-24-year olds were asked to rate the five most popular social media platforms on positive (information, ‘finding your clan’, self-expression, self-identity, accessing other people’s health experience) and negative (anxiety, depression, sleep, cyberbullying, body image) factors. “YouTube was the most positive, the worst was Instagram. Causing poor sleep was a really big issue across them all. The evidence on girls and body image is not good – we’ve seen a huge increase in mental health problems in girls,” says Shirley.
“We asked people what they’d like to see. We suggested a pop-up warning sign after two hours – kids really liked that. We called for social media platforms to show when an image has been digitally manipulated. We suggested NHS England apply its Information Standards to health information on social media, where it’s like the wild west.”
Shirley says the intent was partly to start a conversation. It clearly resonated with the powers that be, especially those with teenage children. “Lots of MPs got in touch – one of them had locked their kid’s phone in a safe. We set up the All-Party Group on Social Media & Young People’s Mental Health. We’re conducting an inquiry; the report is out in Spring.”
There have been spin offs too. ‘Scroll free September’ was a public facing campaign about taking a break from social media. “It was fun, while getting the message across that taking a break might be a good idea.” Using animal motifs, the campaign suggested giving up social media completely for a month (cold turkey), leaving phones charging downstairs overnight (sleeping dog), not looking at social media after six (night owl), at school or work (busy bee) or when you are out and about with mates (social butterfly). Shirley says: “It wasn’t preaching, but keeping the conversation going.”
The 'right thing to do' on drugs
The RSPH has also ventured into drugs policy with Taking a new line on drugs in 2016. I suggest its recommendations can’t have been popular with politicians. “One of the biggest drugs charities went out of business and we said: ‘Who’s doing anything looking at the evidence?’,” she says. “So, we said: ‘Are drugs a public health issue, and do we have a role here?’ We did it because there was a gap, but we wanted to compare drugs across the board, including tobacco and alcohol, through the lens of health harms.
“We worked with a wide range of stakeholders, including police and crime commissioners and the police themselves.” She says you’d be surprised how many were supportive of the line the RSPH eventually took. “The most radical thing in the report was the decriminalisation of personal possession. Our recommendations were specific and doable. Things like drug strategy going to the Department of Health and PHE makes total sense. It’s bonkers that isn’t happening now. Dealing, of course that’s the police, but the user, the addict, should be treated.”
She disappears off for a copy of the report. “Littered throughout it is what the public think,” she says. “Does the drugs classification make sense? No, not really. On overall harm, it’s clear what we are saying. When it came out, we got huge support from public health, quite a bit of the medical community, a front page editorial in The Times agreeing with us, the senior economist at the Financial Times, Martin Wolf, did a huge piece on it. All of a sudden, we realised the report spoke to wider opinion formers. We felt validated; we weren’t funded to do it, but we thought it was the right thing to do. There are loads of people who think this should happen, including people at the Home Office.” I say: “shame about the politicians”. She sighs. “On every bloody level.”
The RSPH is now working with the BMJ to put together a Drugs Health Alliance, to bring the medical community together on the subject. They’re working with The Loop who test drugs at festivals and in clubs. “Kids at festivals are not drug addicts, they’re just out for a good time. The Loop offer to test the drug and tell you what’s in it, and what you are getting is a free drugs consultation. It might be ‘I really wouldn’t take this if I were you, but if you are going to, only take half, and don’t do anything else for six hours, or don’t mix with alcohol’. It’s been a huge success.” It’s catching on. “Glastonbury wouldn’t do it this year, don’t know why, but a lot will, and nightclubs too. These are 18-year olds who don’t need to be dying.”
The end of 2018 sees the RSPH in rude health. Membership stands at over 6,500 worldwide; 50,000 students take RSPH qualifications every year. Six thousand people attended RSPH webinars in the last year, and Shirley says the RSPH publications – the members journal Perspectives in Public Health and the peer reviewed Public Health are growing in importance. “We use our members a lot, we get them involved” she says. RSPH membership includes pest controllers, nutritionists, mortuary managers, doctors, physical exercise professionals, nurses, public health consultants. And 114 pharmacists, and 67 pharmacy technicians. “We may have HLP people in the wider workforce associate membership too,” Shirley adds.
RSPH and pharmacy
It’s provides a useful pivot to the relationship between the RSPH and pharmacy. “We were working with pharmacy well before I got here,” Shirley says. “It’s long been clear to us that having 98 per cent of the population walking by at some time gives you an enormous opportunity to improve and protect the public’s health and wellbeing.”
She continues: “Pharmacy were the first to embrace the wider workforce approach to public health, to see the opportunity for all their staff to champion health and wellbeing and to provide direct support and signposting.” In return, the RSPH has championed the cause of pharmacy, not just in Health on the High Street, but in specific publications like the joint report with Public Health England, Building Capacity, which encouraged commissioners to recognise pharmacy as a local health asset.
“Pharmacy provide some of our best examples. A community pharmacy won one of our awards this year. God, she is amazing,” Shirley says, referring to Olutayo Arikawe, of Priory Pharmacy in Dudley. “It was great to give her an award, to people who are leading the way.”
Shirley has personal experience of pharmacy’s place as a community asset. “My mum worked in the local chemist shop in Maryport, West Cumbria. She knew everyone, as did the pharmacist. It was just a community facility, she loved working there,” she says.
This brings to the HLP register, which RSPH has maintained since it was created. “PHE wanted a register of Healthy Living Pharmacies, initially I think to provide communication opportunities. They had an idea for quality assurance, for people to say you are doing all the things we would expect in an HLP,” Shirley recalls. “They wanted to do QA in a more light touch way, part self-assessment, part testing. We were asked, because of our role in Health Champions and the wider workforce, and because we had that relationship with pharmacy. And RSPH has a long history of accreditation, quality assurance and standard building, so it’s in our DNA.”
The register was established three years ago, and between three and four thousand had joined by the time HLP status was added to the Quality Payment Scheme. “All of a sudden the register was really important. Did that change the perception of it? I honestly don’t know, but obviously then you have a lot more pharmacies becoming HLP officially, partly for the payment, but also because it’s a good thing. Suddenly, we had 8,900 on the register. We have done 125 QA visits, we’ve had some very good feedback from pharmacy.”
The register is funded up to 1 April. “What we want to do, and what we have been asked to do, is make HLP sustainable if we can. We don’t want to have to close the register, so the question is whether the pharmacy sector will support it going forward. This is about leading the sector, something the pharmacy bodies have always done with public health. The QA programme and links to the wider workforce are new developments. We have evaluation tools, impact measurements, we’ve developed a whole raft of things we could be doing with the sector to make this really work.”
PHE say they have no money to continue funding the register, Shirley says. “We would like to take it forward, but it might be that each pharmacy needs to pay a small amount, say 20 quid, to stay on the register,” she says. Now it’s down to discussions with national pharmacy organisations. Shirley is hopeful, especially with new leadership. “This will keep pharmacy ahead of the game,” she suggests. “Between now and the end of March we have to come up with a plan. But it feels like us and pharmacy could work this out.”
Shirley has been meeting the new crop of pharmacy leaders, but she’s not giving too much away about how those conversations have gone. Let’s hope they’ve gone better than the discussions within the Public Health England hosted Pharmacy Public Health Forum. “When this was first mooted they were all ‘woah, something else to pay for’. We may have just hit them at a bad time, but the bigger picture strategically is do pharmacy want this enough?”
Shirley is clear that if the money to run the register is not forthcoming, it will close. “We didn’t get enough money in the first place to do it properly,” she says. “It’s all there, we’re committed to it, but it will need to pay for itself, and contribute to my overheads.”
I ask if Shirley has any advice for pharmacists considering their next steps in public health. “Look locally, it’s all for prevention, and pharmacy has a huge role in that. The opportunities have to be for funding through the integrated care systems (ICSs), because proactive pharmacy could actually be a really important part of the local infrastructure.
“What you need is people and leadership locally that could be funded from the ICS pot to do what needs doing. People will probably say ‘ah, that’ll never happen’, but the opportunity is definitely there. But it does demand some good faith and leadership to work in those systems, with local authorities, the NHS, and making pharmacy a key part of it.”