Wine: the larger the glass, the more you drink

by Sandra Evans - 20 Dec 2017

A recent study shows wine glasses have grown substantially over the decades, with a public health impact as people consume more alcohol.

’Tis the season

The Christmas season is upon us. For many people, this means going out for Christmas parties, catching up with old friends and getting together with family. In doing so, we may raise a glass or two. This season, take a moment to turn your eye to those clinking wine glasses.

During my Master’s degree, I worked on a paper that has just been published in the BMJ. We found that the size of wine glasses in England has increased sevenfold over the past 300 years. This rise has been steepest in the last two decades, as wine consumption has risen.

This raises the question of whether downsizing wine glasses might reduce consumption – bringing clear health benefits.

Wine glasses through the years

Wine glasses from the early 17th century were far smaller than they are today. They were usually kept on the sideboard and brought by one’s butler when one wanted to make a toast. But as glass became less brittle, with the invention of lead crystal glass by George Ravenscroft in the late 17th century, glasses became more extravagant in their design. Wine glasses began to move to the table and, gradually, glass size started to increase.

This size increase of wine glasses parallels the explosion of the middle class associated with the industrial revolution. This new middle class created a huge wine market.

Size matters

While wine glass size was already gradually rising, there was a sharp increase in the late 20th century. This is probably due to demand from the US market, and the promotion of larger wine glasses by bars to boost profits. A recent study showed that larger wine glasses have been associated with increased sales.

Humans consume in units: one cup of tea, one chocolate bar or one glass of wine. People tend to drink a glass of wine regardless of its volume, because they regard one glass as a whole unit. If someone perceives a glass as mostly empty, they are less likely to feel satisfied after drinking it than they would if they drank the same volume from a full, smaller glass. This means people may be more likely to have a second or third glass when they are drinking ‘unsatisfying’ portions from a large glass.

Designing our environment

For years, marketing has been designing the environment around us, through product placement and design to increase our consumption – sometimes to the detriment of our health and wellbeing.

But this can work the other way around. Health promotion campaigns can use the same method to design the environment around us to ‘nudge’ people to make healthier choices. We can use design to de-incentivise ‘bad’ health choices, thus making ‘good’ health choices the reflex option.

If policymakers were to regulate wine glass sizes as part of licensing regulations, we might feel more satisfied after our small-but-full glass of wine at the pub. This could mean we order fewer glasses and, ultimately, drink less – a welcome boost to our health and wellbeing, particularly in the festive season.

Palliative care should not be a last resort

by Suzanne Wait - 06 Dec 2017

Palliative care exists to reduce suffering and improve patients’ quality of life. So why is it often unconsidered until other options have been exhausted?

Last month, I had the opportunity to speak on a panel on palliative care at the Economist’s War on Cancer event in London. The discussion powerfully reconfirmed something that has struck me time and again in the work we’ve done with patients on All.Can and other HPP projects: that a patient’s ability to cope with the physical, psychological and emotional effects of their illness is often not considered in their treatment.

What is palliative care?

Many people consider palliative care to be the care offered when ‘real’ – i.e. curative – treatment options have been exhausted. But what it really means is care focused on improving quality of life for patients with a serious illness, regardless of the stage of that illness.

The American Cancer Society is among the organisations advocating that palliative care be fully integrated into cancer care, to ensure patients receive relief from the effects of their treatment throughout the care journey, not just at the end. Studies have shown that the early introduction of palliative care for cancer patients can not only improve patients’ quality of life, but may also reduce their need for intensive care and prolong survival, while being cost-effective for healthcare systems.

There is evidence that patients are far more likely to seek palliative care services if their oncologist recommends it and makes a referral. So why isn’t palliative care more readily offered during the early stages of treatment?

Palliative care is too often associated with failure, death and lack of hope. Doctors are hesitant to raise the subject, and patients don’t want to hear about it. This can have devastating consequences. A study across several European countries found that in a third of cases, patients with advanced cancer did not receive pain control appropriate for their level of pain. It is shocking to think of patients enduring avoidable pain, simply because of an aversion to broaching a subject.

Psychosocial elements of care

Earlier this year, I contributed to a position paper by the European CanCer Organisation (ECCO) on access to innovation. One of the areas of innovation we found to be inadequately adopted in many cancer centres was a systematic psychosocial assessment for every cancer patient.

Patients consistently report that they feel abandoned after their ‘active’ phase of treatment and care. They are left without support to improve or maintain their quality of life, deal with long-term effects of treatment, or cope with the psychological aspects of living with cancer. Clearly, there is something wrong. There is an urgent need for greater follow-up care after ‘active’ treatment. Palliative care can play a key role here, as it focuses on improving patients’ quality of life.

Rethinking palliative care

During the War on Cancer session, we considered whether palliative care needs rebranding. Many health systems now call it ‘supportive care’, to reduce negative associations. But this is not just about a name change. We need a philosophical shift to embrace palliative care as an integral and essential component of quality cancer care. This reframing could create huge benefits for patients. Less stress, less pain, more support, increased quality of life and, as studies have shown, potentially longer survival.

With the excitement created by advances like immunotherapy, genetics and artificial intelligence, there is a risk that we forget to focus on addressing the basic tenets of cancer care – including palliative and end-of-life care. The entire discourse around ‘fighting’ cancer is problematic; the idea of an epic battle or quest inevitably frames death as a tragic failure. A relentless focus on survivorship may leave little room for the emotional, psychological and often practical realities of life with (or after) cancer, which are so important for patients and their families. This is an area in need of attention if we are really going to improve outcomes for cancer patients.

Survivorship is, of course, the outcome we all want. Innovation in cancer care is enormously exciting and, obviously, worth striving for. But the early and appropriate introduction of palliative care in the cancer pathway should be seen as an important innovation in its own right. We must never lose sight of the need to do everything possible to improve and protect patients’ quality of life, whatever the prognosis.

An extended version of this blog post was originally published on the All.Can website.

Software is eating the world… except in medicine

by Shannon Boldon - 30 Nov 2017

We are living in a golden age of technological invention, so why are healthcare systems seemingly reluctant to get on board with innovative software?

A week after attending the Economist War on Cancer event, I am still thinking about the discussions from the Digital Health & Cancer Care panel. Data and technology have transformed the way we do things in many industries. From Uber to Ocado to Airbnb, there are so many examples of radical game-changers for consumers. The words of Andaman7 CEO Vincent Keunen have not rung truer: ‘Software is eating the world – except in medicine.’

Innovative software in healthcare

But why is medicine not catching up? It is not for a lack of interesting, game-changing technology in healthcare, that’s for sure:

  • Babylon Health offers a service allowing people to book a GP appointment or have a video or phone consultation with a doctor 24/7, through a smartphone app.
  • IBM Watson Health’s artificial intelligence (AI) technology has shown 90% concordance with tumour board recommendations on breast cancer. Watson, used for early detection of melanoma, has been shown to give a 95% level of accuracy (compared with that achieved by dermatologists) in initial studies of detecting dangerous skin lesions.
  • Smartphone app Natural Cycles provides women with a certified contraceptive method that is non-hormonal and non-intrusive.

Despite these innovations, healthcare systems and practitioners seem reluctant to embrace the potential of new technologies.

Resisting change

Perhaps the reason for this is a fear of change, or ingrained professional attitudes that are resistant to a transfer of power. Or perhaps it’s a more extreme fear: that robots might, one day, replace doctors.

Among the speakers on the digital health panel at the War on Cancer event was Dusty Majumdar of IBM Watson Health, whose artificial intelligence sequencing technology has allowed doctors to sequence glioblastomas (a rare and aggressive form of brain tumour) in ten minutes, rather than seven days. Majumdar pointed out that fear of automation is misplaced, saying: ‘It is not a matter of machines replacing doctors: it is more that radiologists who use artificial intelligence will replace radiologists who do not use artificial intelligence.’

Meanwhile Neil Bacon, founder of patient feedback website iWantGreatCare, eloquently summarised his take on digital health: ‘These new technologies have side effects, like all drugs ever. But we must find them, and mitigate them. Do not let perfect be the enemy of good.’

Regardless of individual opinions, it is only a matter of time before technology will change the way we deliver, and engage with healthcare. For better or for worse and my guess is the former.

Speakers at the Economist War on Cancer event (L-R): moderator Vivek Muthu, Neil Bacon, Vincent Keunen and Dusty Majumdar


Antimicrobial resistance: is it too late to suppress the superbugs?

by Madeleine Murphy - 16 Nov 2017

World Antibiotic Awareness Week reminds us that we all have a role in solving one of the most pressing crises in global healthcare.

Imagine we have travelled through time, to a world where there are no organ transplants, no joint replacements, and no cosmetic surgical procedures. Even in the world’s richest countries, maternal and infant mortality rates skyrocket, and common infections claim thousands of lives every year.

You might assume that we’re in the past, before scientific endeavour brought about the medical procedures and treatments we now take for granted. But unfortunately not. This is, potentially, the future – a bleak world in which antimicrobial resistance has nullified many of healthcare’s pivotal achievements.

What is antimicrobial resistance?

Antimicrobial resistance occurs when microorganisms, such as bacteria, mutate and become resistant to antimicrobial drugs, such as antibiotics. Although it’s a natural evolutionary process, it is hugely accelerated through misuse of these drugs. But you didn’t need me to tell you that – you’ve heard all about it already. In fact, we’ve known about resistance to antibiotics for almost as long as we’ve known about antibiotics themselves.

In 1945, having just won a Nobel Prize for the discovery of penicillin, Alexander Fleming warned that it was ‘not difficult to make microbes resistant to penicillin in the laboratory’ and that ‘the same thing [had] happened in the body’. He correctly predicted that inappropriate use of antibiotics might lead to the spread of resistance among bacteria. But even Fleming probably didn’t foresee quite how inappropriate our use of antibiotics would become.

Misuse of a miracle

Antibiotics were once hailed as a ‘miracle cure’. As with most miracles, this was too good to be true. Excessive use of the drugs has hindered their effectiveness. In 2015, Nature reported that global antibiotic consumption grew by 30% between 2000 and 2010. Despite awareness of antimicrobial resistance, particularly concerning antibiotics, clinicians continue to prescribe these drugs even when they’re not needed. Sore throats, for example, are usually viral infections; only 10% will respond to antibiotics, and yet antibiotics are prescribed in as many as 60% of cases. The US Centers for Disease Control and Prevention (CDC) has reported that at least 30% of antibiotics prescribed in the US are unnecessary.

Overprescription has contributed to a rise in antibiotic resistance. As a BBC report points out: ‘Bacterial resistance is essentially a numbers game: the more humans try to kill bacteria with antibiotics, and the more different antibiotics they use, the more opportunities bacteria have to develop new genes to resist those antibiotics.’

Underuse is another part of the problem. In some countries, poor access to antimicrobial treatments may force patients to use substandard alternatives or take an incomplete course. While there is debate over whether antibiotics must be taken as an entire course, there is evidence that exposure to suboptimal doses makes bacteria more likely to develop resistance. To paraphrase Friedrich Nietzsche: what doesn’t kill you makes you stronger.

Of course, antibiotic use is not limited to healthcare. A huge culprit in the misuse of these drugs is the agriculture industry, where they have been used not only to prevent infection but also to promote animal growth. Although the EU banned antibiotics as growth promoters 10 years ago, other countries continue this practice. The US Food and Drug Administration only removed growth from the indicated uses on drug labelling in 2017. In China, around 15,000 tons of antibiotics were used in livestock in 2010, and the country’s antibiotic consumption is projected to double by 2030.

The rise of antimicrobial resistance is compounded by the dearth of new drugs. Owing partly to a lack of incentives, research and development is slow; only two new antibiotic classes have been introduced in the past 40 years. Given the speed with which bacteria can develop resistance, it’s not hard to see why we are losing the arms race.

What would a world without antimicrobials look like?

The dystopia to which I alluded at the start of this post – and which forms the setting of a recent science-fiction comic book series – may seem extreme, but the reality is that we are hugely dependent on antimicrobial drugs. Antibiotics are essential for infection prevention in surgery, so it is likely that minor operations would be considered too risky without them. Additionally, anyone with a suppressed immune system – owing to chronic illness, cancer treatment, organ transplants or any other reason – could be at risk of death even from minor infections.

And it’s not just antibiotics. Antiviral medications are also coming up against resistance. There have been reports from various countries of drug-resistant influenza, malaria and HIV. This is a global problem, requiring a global solution – and time is running out.

How can we combat antimicrobial resistance?

Without buy-in from all stakeholders, we can’t realistically expect to win the fight against antimicrobial resistance. The World Health Organization is using this year’s World Antibiotic Awareness Week (13–19 November) to raise awareness of what we can all do to combat the crisis. Any solution must be viewed as a continuum, including infection prevention, incentives for research and development, improved surveillance and diagnostics, alternative treatments and widespread behaviour change. As emphasised in an editorial in The Lancet Global Health, everyone has a role to play, including patients, researchers, healthcare providers, farmers, veterinarians, the media and policymakers.

Only by taking responsibility for our part in this problem, and acting accordingly to solve it, will we see a brighter future. Let’s do all we can to ensure that the dystopian vision of a world without antimicrobials retains its rightful place – in fiction, not reality.

Cancer survivorship: supporting patients throughout care and beyond

by Suzanne Wait - 16 Oct 2017

A session at this year’s European Society of Medical Oncology congress focused on rehabilitation and survivorship, a crucial element of the cancer care journey for patients.

A few weeks ago, my colleagues and I were among the 20,000 people who attended the European Society of Medical Oncology (ESMO) congress in Madrid. Particularly exciting this year was that the Patient Track sessions were an integral part of the programme – allowing ‘non-clinical’ topics of high relevance to patients and caregivers to be discussed. Such topics typically do not feature in the more clinically focused sessions of these congresses.

Rehabilitation is fundamental in cancer care

Among many excellent sessions, one that most struck me was called ‘Lost in rehabilitation’. The premise was that rehabilitation is a critical part of the cancer care journey for patients, and that greater efforts are needed to embed it into cancer care plans, as well as individual patient care and support. During the session, rehabilitation was defined as the general return of people who had been diagnosed with cancer into society and everyday life – going back to work, trying to resume a ‘normal’ life as men and women, parents, children and friends, developing relationships – and learning to put their diagnosis of cancer behind them, as much as possible.

I heard some incredibly poignant testimonies from cancer patients, talking about how they felt lost in their attempts to resume a normal life after their cancer treatment ended. One woman spoke of her deepest wish to ‘hang up the “cancer patient” label’ after her treatment was over. Another talked about being denied health insurance because of her cancer diagnosis. Many reported the difficulties of returning to work or applying for a new job, or discussing career advancement. The sense of loss was as much in their ability to navigate the nebulous zone of ‘after-care’ as in adjusting to the emotional – and sometimes physical – aftermath of a cancer diagnosis and treatment. As a close friend of mine, who was diagnosed with cancer at the age of 35 with two small kids, said: ‘The treatment is horrible. But the toughest bit is the mental bit – and that never goes away.’

Cancer survivorship: a recent concept

These discussions may not have even taken place 10 years ago – when the notion of cancer survivorship was, in Europe at least, in its infancy. It is a testament to the transformational advances in treatment and care in recent years that the notions of cancer survivorship and rehabilitation are becoming ever more prominent in today’s policy discussions. For example, several academic papers have called for better social and employment policies to support cancer survivors and their employers to enable their return to work. At ESMO, the European Cancer Patient Coalition (ECPC) and ESMO launched the ESMO–ECPC Survivorship Guide, to foster a dialogue between cancer patients and healthcare professionals to help patients return to a ‘normal’ life. It includes a checklist that may help ensure each patient has a survivorship care plan that considers rehabilitation, late effects and second cancer prevention, as well as a smooth return to work as appropriate.

The fact that we can talk about cancer survivorship is, of course, a huge cause for celebration. Many patients whose prognosis previously would have been very limited may now have the hope of living ‘with or beyond cancer’ – often for many years, and with very good quality of life. Some patients may be on treatment for the rest of their lives – but still able to enjoy life. Others may be lucky enough to be considered in long-term remission or ‘cure’ – although this term is still used with great caution in cancer care.

Thinking beyond survivorship

It is so important, however, to remember that survivorship is not available to everyone. One in every three people diagnosed with cancer does not survive more than five years. All of us working in cancer policy or advocacy must always keep in mind the diversity and individuality of the cancer patient experience. I recall, for example, doing work on metastatic breast cancer and reading that, for many women living with the as-yet-incurable condition, the month of October – where the world goes pink and brandishes the pink ribbon representing hope and survival – fills them with dread, as it reminds them of their ‘failure’ to achieve survivorship. These women feel forgotten, or lost, in their cancer experience.

As advocates, researchers, scientists and clinicians, we need to fight for better diagnosis, care and support for patients and their families at every stage of their care, and after-care. This includes recognising the risk of patients feeling lost, forgotten or abandoned at any stage in their experience. We must always think of what matters most to patients – ensuring that no patient, current or former, feels abandoned in their efforts to gain control of their lives, despite cancer.


This blog post was originally published on the All.Can website.

Air pollution: the heart of a health crisis

by Christine Merkel - 19 Sep 2017

Air pollution is a significant contributor to cardiovascular, respiratory and other diseases. And with levels of pollution rising, policymakers must act to safeguard the health of their populations.

Just five days into 2017, one road in London had already exceeded its air pollution limit for the entire year – with many others soon to follow. In ‘mega cities’ such as Beijing, periods of extreme air pollution lasting weeks are becoming the norm. And, shockingly, 2014 figures revealed 92% of the world’s population was living in places that did not meet the World Health Organization (WHO) air quality guidelines.

Air pollution disproportionately affects developing countries. The WHO announced in 2016 that 98% of cities in low- and middle-income countries did not meet air quality guidelines. In high-income countries, meanwhile, this figure was 56%. Considering the health impacts of air pollution – not to mention wider environmental effects – it is imperative that we act to reduce it.

What is air pollution?

Environmental (also known as ambient) air pollution arises from many sources. Among other things, sources include fossil fuel combustion from cars, coal power plants, and solid fuel burning at home. This pollution is a mix of gases and other particles, each of which can be harmful and affect the body differently. These include particulate matter and gases such as ozone (O3), nitrogen dioxide (NO2) and sulphur dioxide (SO2).

Particulate matter (PM) is a mixture of very small particles and liquid droplets that get into the air. This type of pollution affects people more than any other pollutant. When inhaled, PM can penetrate the lungs and even the vascular system. Negative effects have been noted from both very short-term and long-term exposure.

The smallest type of PM (fine PM of 2.5 microns: PM2.5) has been noted by the WHO to have ‘no threshold… identified below which no damage to health is observed’. PM2.5 alone has been estimated to cause 3.15 million deaths per year – and this is set to double by 2050. The greatest burden occurs across much of Asia and the Pacific.

Together, ambient air pollution and tobacco smoking are significant contributors to morbidity and mortality. In the 2015 Global Burden of Disease study, they are the fifth-highest and second-highest risk factors, respectively. I’m not going to delve into ‘personal’ air pollution via tobacco smoking, but it is an avoidable cause of death and disease that directly impacts the health of the smoker and others around them, so could also be argued to contribute to ambient air pollution.

What are the health impacts of air pollution?

Air pollution causes or aggravates numerous diseases and health issues. Some of the most obvious are those associated with the lungs: asthma, emphysema and chronic bronchitis. But even short-term exposure to air pollution can also increase risk of heart attack, stroke and congestive heart failure. Exposure to air pollution has been linked to higher rates of hospital admission and mortality for heart failure and stroke. This puts a significant burden on healthcare systems, not to mention patients and their families.

Risks are magnified among vulnerable groups – minorities, older people, children and people with pre-existing conditions. For pregnant women, pollutants can negatively affect a foetus and cause long-term health problems including congenital heart defects, obesity and predisposition to cardiovascular disease (CVD). Our knowledge of the impact of air pollution in utero is limited, but it has been shown that the ‘dose’ of pollution experienced by the foetus may be relatively higher than that of the mother.

Medical advances have led to more people surviving cardiovascular events and living with CVD, such as hypertension. This means a vast number of people will be affected if governments do not take action to combat air pollution.

What can be done?

Many people – including healthcare professionals and policymakers – often fail to appreciate the cardiovascular health risks of air pollution. The respiratory effects are easier to identify, but long-term exposure to air pollution can also have serious cardiovascular health implications. Although awareness of CVD is growing, the impacts of pollution are still not widely known.

There is clearly a case for change, from both a health and an environmental perspective. But when it comes to ambient air pollution, policymakers and leaders across a range of sectors have a duty to protect citizens. Even modest improvements and incremental change in air quality can lead to increased life expectancy over short timeframes. Whether it’s by reducing traffic, planning healthier cities and developments, passing anti-smoking legislation or regulating industry, there is much that can be done.

But too few countries meet WHO air quality guidelines and, all too often, there is not enough action at a national level. Air pollution control measures face countless barriers; increasing ‘green’ power infrastructure can be economically and politically challenging. Meanwhile, international treaties and national policies are often ‘toothless’ and end up being ignored. But there can be no doubt that this is a public health priority. Until policymakers act to overcome these obstacles, millions will continue to live in – and be harmed by – increasingly unhealthy environments.

What is health? The search for an accurate definition

by Sandra Evans - 06 Sep 2017

We may think we understand what health is, but is there a clear definition? And how has the notion of ‘healthy’ changed over time?

It may seem an obvious question: ‘Do you know what “health” means?’ But there is much debate over the definition.

The World Health Organization (WHO) defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’. But how accurate is this? Consider a person who has diabetes and manages it with medication, or someone who has back pain that they manage with physiotherapy. These people are clearly not in a state of complete physical wellbeing. But does that make them unhealthy?

Health: all or nothing?

Perhaps infirmity and disease can coexist with health. This would mean that there is not a binary ‘healthy’ or ‘unhealthy’ state, but rather a spectrum. In our lifetimes, we all experience periods of good and bad health. And we may even experience the two states at the same time.

Huber and colleagues suggest that the problem with the WHO definition is the absoluteness of ‘complete’ wellbeing. This, they suggest, inadvertently contributes to the ‘over-medicalisation’ of the population. It allows a platform for industry, medical technologies and professionals to redefine our health status. In effect, it could imply that no one is ‘healthy’ any of the time, and everyone needs some level of treatment for any given condition. It doesn’t allow the individual to define their own health, and their own health goals.

Resilience and management

When the WHO defined health in 1948, it was revolutionary in its notion that health means more than the absence of disease. However, Huber et al. suggest that, owing to our ageing population and the increasing focus on management of communicable diseases, this definition is no longer fit for purpose. They propose shifting the emphasis of health towards the ability to adapt and self-manage in the face of social, physical and emotional challenges.

This echoes the concept of resilience, which has been defined as ‘the capacity for populations to endure, adapt and generate new ways of thinking and functioning in the context of change, uncertainty or adversity’.

Your life, your health

Thanks to medical advances and disease management, the concept of health now encompasses more than traditional definitions encapsulate. There is a level of health that each of us can aspire to attain. Every person is exposed to a unique selection of beneficial and adverse circumstances over the life course. Ultimately, it is how we manage – and adapt to – these circumstances that defines our health status.

Public health priorities vs. societal realities

by Madeleine Murphy - 29 Aug 2017

Science and policy agree that smoking is bad for health, and breastfeeding is good – so why don’t public attitudes reflect this consensus?

Here are a couple of things we know, thanks to decades of scientific evidence:

  1. Smoking tobacco is bad for health.
  2. Breastfeeding is good for health.

Public health policy reflects this knowledge. In the EU, the revised Tobacco Products Directive in 2016 placed restrictions on the packaging, sale and marketing of cigarettes. In the UK, 2017 marks the 10-year anniversary of the ‘smoking ban’ – legislation that prohibits smoking in public places and workplaces. Smoking prevalence in the UK has since dropped from 20.9% to 16.1%.

Meanwhile, the World Health Organization (WHO) recommends that women breastfeed exclusively for the first six months of the infant’s life, then continue to breastfeed (alongside solid food) for up to two years. EU policy has long promoted breastfeeding, and health professionals advocate it as the best method of infant feeding. However, according to the WHO, the European region has the world’s lowest rates of breastfeeding.

Social attitudes

Why has one of these public health messages been successful, and the other a comparative failure? Although the law says breastfeeding is acceptable everywhere, while smoking is unacceptable in many areas, social attitudes often don’t reflect this. News outlets frequently report breastfeeding women being asked to cover up or stop breastfeeding in public. This can cause shame; in a UK survey, 36% of women said breastfeeding in public was embarrassing. It may be a reason why some women discontinue breastfeeding earlier than recommended.

Smokers are not exempt from social reproach; there is evidence that some feel increasingly stigmatised. But the key difference is that the overall health effects of tobacco are harmful. Worldwide, it kills more than 7 million people every year. Breastfeeding, meanwhile, harms no one and brings numerous benefits to both infants and mothers.

Public health in the workplace

For women to adhere to the WHO recommendation of breastfeeding for up to two years, those who are in full-time employment must be able to express breast milk while at work. EU legislation requires employers to provide a rest break for all employees every six hours, but this may not be frequent enough – nor the individual breaks long enough – for women who need to express milk.

Employers in the UK are required to provide ‘suitable facilities for breastfeeding mothers to rest’. However, the reality faced by many women returning to work is that there isn’t an appropriate area for expressing milk. In many cases, the only space available might be an office or meeting room, offering limited privacy. Some women resort to expressing in toilets for want of a suitable space – an unhygienic and unpleasant experience.

Meanwhile, UK employers are not legally obliged to have designated external smoking areas for employees – yet many do. Despite the compelling evidence to support the benefits of breastfeeding and the negative impact of tobacco, we make it easier for people to smoke than to express milk.

Changing perceptions

If the problem is perception, what can be done to change people’s views? One crucial element may be normalisation of positive health behaviours. Health professionals and breastfeeding advocates have long argued that the solution to negative attitudes to public breastfeeding is promoting it as an everyday activity. The more people see something, the more they accept it as part of life. This is one of the key arguments against advertising infant formula, which can reduce women’s confidence in their ability to breastfeed.

This notion is not unique to breastfeeding. Many countries have banned tobacco advertising. Recent measures taken in the UK include the introduction of standardised ‘plain’ packaging for cigarettes. In Australia, where plain packaging was introduced in 2011, it has been shown to reduce the appeal of cigarettes to adolescents. There is also evidence that, just as peer pressure may encourage young people to take up smoking, supportive peer networks can have a positive influence on people trying to quit.

A holistic policy approach

Public health policy is based on evidence. Conveying this evidence in a way people understand and relate to is not always easy. Anti-smoking campaigns in several countries, particularly the UK, have had a positive impact. Breastfeeding promotion, meanwhile, has failed to strike a chord with the public, despite overwhelming evidence.

Perhaps we need to take a more holistic approach to health promotion. The Royal College of Paediatrics and Child Health recently recommended that ‘familiarity with breastfeeding’ should be included as part of statutory personal, social and health education in UK schools. An intersectoral approach could be effective in normalising breastfeeding and guiding public opinion. But it is essential to strike the right balance between recommendation and instruction. As soon as public health guidance starts to feel like pressure, there is a risk of alienating people. And that’s when messages stop getting through.

Achieving public health goals requires hard work, but the success of promotion around smoking cessation shows what can be achieved. To have a real effect on mainstream health behaviours, policy and public opinion must move in the same direction. This can be challenging, but it’s a challenge worth facing to improve the health of the population, both today and for generations to come.

Innovation in health service delivery: elegant solutions to transportation barriers

by Christine Merkel - 09 Aug 2017

Collaboration with tech companies has potential to introduce innovation that combats barriers to accessing healthcare.

Innovation in healthcare delivery seems to be everywhere right now, particularly with the burgeoning market for apps. I recently read a paper that pushes innovative delivery of healthcare into new realms. Nonemergency Medical Transportation: Delivering Care in the Era of Lyft and Uber, by Powers et al., describes collaboration between ride-sharing apps and healthcare providers, which is making headway in breaking down barriers to attendance of non-emergency care appointments.

Patients with the highest burden of chronic diseases typically have some of the greatest transportation barriers. In 2005, approximately 3.6 million individuals in the United States failed to receive non-emergency medical care because of such barriers. This ride-sharing innovation could be an important step to improving access to care and, eventually, health outcomes – particularly for elderly, poorer and minority groups.

Service improvements

The article describes early results from a pilot programme between a payer and Lyft, which provides a dramatically better service than the existing options of traditional taxis or livery services. It demonstrated 30% shorter waiting times and patient satisfaction of over 80%. Furthermore, it was estimated that the cost per ride was reduced by a third over the typical service. A dedicated web-based tool allows caregivers, nurses and patients to book rides and track them in real time. This means that not having a phone is no longer a barrier to digital transportation services.

Another trial, in a different area and with another care provider, used Uber. It noted no-shows being just 8% of all rides, compared with 25–50% for traditional services. Clearly, there is a significant opportunity to improve care and access, while saving costs in the long term.

There are many possibilities for such services, beyond transporting people to and from appointments. They could deliver medication, support carers in their activities, or support a wide range of other health or social services.

Digital transportation services are also aiming to revolutionise travel for disabled passengers. There is huge potential to allow greater freedom and ability to travel than ever before. Traditional transport is known to be expensive and unreliable; with digital transport services, people can book adapted cars and drivers can receive additional training.

Implementing innovation

Of course, such services will always have hiccups and more endemic issues. It is essential that drivers be provided with adequate training in the needs and challenges of these specific groups of passengers. Then there is the perennial issue of access. Many of these services are only available in urban areas, and accessible cars may not be an option in all markets.

The Powers et al. study was carried out in the United States, so may not be entirely applicable across the UK and Europe, which often have better public transport infrastructure. But tremendous barriers still exist in attending healthcare appointments – especially for people with a low income or mobility issues.

There must be better support for people with chronic diseases and underserved groups to attend non-emergency appointments. People should be helped to access readily available care, particularly those in rural populations and lower-income groups. Improved access through innovative delivery of care, such as digital transport providers, seems a simple – even elegant – solution. I think there is significant potential here; in a challenging healthcare economy, we need to think outside the box. Healthcare providers should consider collaborating with seemingly untraditional partners, to reduce barriers to care and support people to manage their health.

Mental health: designing and delivering services with the public

by Sandra Evans - 03 Aug 2017

Person-centred care is fundamental to mental health provision, empowering people to take charge of their own health and behaviours through understanding and collaboration, rather than enforcement.

Mental health is one of the most prominent issues in healthcare today. From my experience of working in mental health, I’ve come to learn that person-centred care is essential to empowering individuals to work towards recovery.

What is person-centred care?

There are various definitions of person-centred care. The Health Innovation Network South London explains it concisely:

‘Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs. This means putting people and their families at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome.’


Person-centred care is not a new concept. National guidelines – such as National Institute for Health and Care Excellence (NICE) guidance in the UK – state the importance of person-centred care in caring for people with mental health conditions.

However, understanding of person-centred care, such as common definitions and guidance on implementing it in practice – is not well established. This can result in scepticism and tokenistic engagement of patients and carers.

Experts by experience

Healthcare professionals may be experts by training, but patients and carers are experts by experience. Given that they are the ones for whom the service exists, we should be listening to them about what they want and need.

It is not enough to consult these experts by experience as a second thought – they need to be involved in the decision-making process from the beginning. The views of clinicians and policymakers on what is important to a person’s recovery might be worlds apart from that person’s own perspective. Involving experts by experience at every level of decision-making ensures that the service on which we are spending money is actually beneficial to those whom it is for.

Gellinudd Recovery Centre: co-designing a mental health service

In Wales, a mental health centre recently opened that has been co-designed and co-delivered with experts by experience. Designing the centre took three years of consultations – the experts by experience met with the architects and designers throughout the process, and were involved in the development of the centre’s holistic approach. Gellinudd Recovery Centre is a great example of meaningful engagement and person-centred care.

Guests and staff at the centre meet regularly, to develop and evaluate the service and their holistic approach. This approach looks at work, relationships, finance, sociocultural and spiritual beliefs, education, accommodation, medical and psychological interventions, and wellbeing.

Person-centred care in all health policy

Empowering people to take charge of their own health status and behaviours is both ethically advantageous and cost-effective. Studies have shown that improving individuals’ self-management and involving them in shared decision-making can lead to reductions in future service usage.

Person-centred care and meaningful engagement with people who are experts by experience should be a staple of all health policy and practice. Mental health, obesity, heart disease, diabetes and cancer are today’s – and tomorrow’s – major global health concerns. These conditions are associated with certain behaviour patterns linked with individuals’ wellbeing, environment, resilience and support systems.

There are numerous positive public health interventions, such as tobacco control, alcohol minimum pricing, and taxes on high-sugar food and drink. But these should be part of a package of interventions that focus on empowering people to change their behaviours for themselves – and not just because an unhealthy lifestyle costs more.

This goes beyond the traditional health promotion tools of taxation, information provision, legislation and so on. We need more research and investment in designing services that involve people, and allow individuals to be involved in every step of the decision-making process. This will allow everyone to be an active contributor to not only their own health, but also the wider healthcare system and overall environment.

To read more about this topic:

The Health Policy Partnership has published previously on mental health, person-centred care and public involvement in health. See the relevant sections on our Publications page, or read our global synthesis report on The state of play in person-centred care.