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The health of the nation

One of the incidental effects of the coronavirus crisis was to lift obesity high up the public health agenda. Charities and medical royal colleges in the UK had been campaigning for years for measures to reduce consumption of salt, sugar and fat, especially by children, but had achieved only limited results. The biggest breakthrough had come in 2016, when the government introduced the Soft Drinks Industry Levy, which taxed producers of drinks that contained more than 5 grams of sugar per 100 millilitres. When it came into effect two years later, a minister – making use of a calculation by CRUK – acknowledged that teenagers consume ‘nearly a bathtub of sugary drinks each year’.¹ The campaign had been led by Sustain, a charity that runs a variety of projects to improve food and farming, backed by the chef and food writer Jamie Oliver. Once the tax came in, however, campaigners felt that any further measures were being kicked into the long grass by the government.

All that changed after the Prime Minister, Boris Johnson, emerged in April 2020 from intensive care after a battle with COVID-19. Doctors were already becoming aware that obesity was a factor in the disease, and on 25 July Public Health England issued a report saying ‘people with Covid-19 who are living with overweight or obesity, compared with those of a healthy weight, are at increased risk of serious Covid-19 complications and death’.² Two days later the government announced new measures to combat obesity, including a ban on TV and online advertising before 9 pm of foods high in fat, sugar and salt.³ The announcement was accompanied by an interview with Johnson saying he had been “way overweight … I was too fat”.

The episode was an example of how the personal experiences of people in power can suddenly give momentum to long-standing, but struggling, charity campaigns. As part of its Children’s Food Campaign, Sustain had been pressing for more than ten years for the TV ban, which its deputy chief executive, Ben Reynolds, welcomed as ‘real game-changer’.⁴ He pointed out that obesity was not just about personal willpower: ‘You just have to look at the environment that we live in – the torrent of unhealthy food that bombards us – dominating advertising, our high streets, through to in-store promotions – it’s everywhere.’

The difficulties of making headway against the opposition of the food industry and some politicians prompted the formation in 2015 of the Obesity Health Alliance, which has more than 40 members including health charities such as Diabetes UK, the British Heart Foundation (BHF) and CRUK, and medical royal colleges. It has agreed ten policy proposals, of which the main ones are restricting the promotion and marketing of unhealthy food and drinks, and reformulating food products to reduce calories and sugar. Caroline Cerny, Alliance lead, says that charities played a vital role in the Alliance:

“The medical royal colleges are useful for their clinical voice, and they can put up some knowledgeable experts who can give real insight into how obesity is affecting their clinical practice. When you’re trying to meet ministers, charities can open doors – they carry weight because they are seen as having credibility with the public. They also have a big reach and can get their supporters involved. The big charities can also get meetings with a broader focus – with the DCMS about advertising, for example.”

Cerny says the proposed ban on advertising before 9 pm was a breakthrough because it was “a population-wide measure”, as opposed to policies focused on individual choice and responsibility, which tend to be favoured by a government sceptical about ‘the nanny state’. But she says there is still a long way to go – the measure needs primary legislation, and the food industry is fighting back.

The charity campaign against tobacco

While progress on obesity remained piecemeal, the campaign on smoking had already scored a big hit. By 2020 it seemed inconceivable that people should ever have eaten meals in restaurants full of cigarette smoke. As recently as the year 2000, smokers could still light up pretty much anywhere, except on aeroplanes and the London Underground. But within a few years that seemed plain wrong – the thought of a pub or sports clubroom thick with tobacco haze became repellent to most people.

Even the power of the tobacco lobby, and the substantial revenues from taxes on tobacco – an estimated £9.1bn in 2019/20, according to the Office for Budget Responsibility – could not prevent the enactment of the law against smoking in public places.⁵ Public opinion shifted dramatically: when a ban was first mooted in 2003, people were either indifferent or firmly opposed, depending, usually, on whether they smoked or not. But public support for a ban doubled between 2003 and 2005.⁶ And by the time the Health Act was passed two years later, making it a criminal offence to smoke in premises that are open to the public or constitute someone’s place of work, there was overwhelming support for the change.⁷ So what happened in a mere four years to turn the issue on its head?

The answer, in short, is a highly effective campaign spearheaded by a tiny charity called Action on Smoking and Health (ASH). It was set up in 1971 by the Royal College of Physicians after the UK government refused to act on the College’s demands for policies to cut smoking. ASH gets nearly all its funding – about £765,000 in 2019 – from two other health charities, the BHF and CRUK, and uses it to influence public policy on tobacco. It coordinates the Smokefree Action Coalition, the umbrella group formed in 2003 to campaign for the ban on smoking in public that eventually comprised more than 60 organisations. When the Coalition started lobbying for smoke-free legislation, the debate was framed very much around what were called the ‘rights’ and ‘freedoms’ of smokers. But ASH opposed this by promoting the rights of employees not to be subjected to potentially lethal second-hand smoke at work.

This health message changed the debate. The former Labour MP Kevin Barron, an ardent anti-smoking campaigner who chaired the health select committee of MPs at the time, says that it was science that won in the end by proving that breathing in secondary smoke was damaging, and that it was ASH and other charities that brought this science to the attention of the public and policy makers. “At the time there were more than 120,000 people dying a premature death each year in the UK because of smoking,” says Barron. “If that was road traffic accidents or war, we’d try and stop it.”

The campaign employed tactics including public opinion polls, briefings of MPs, proactive and reactive media work, direct contact with local authorities, employers and legal experts, and profile-raising events. In a review of the campaign, ASH staff wrote that building the evidence base for their messages was of key importance, as was making it public at the right time.⁸ ‘For example,’ they wrote, ‘when health minister John Reid said he feared that banning smoking in public places would lead to more smoking in the home, so harming children, a paper was put together for a Royal College of Physicians’ report collating the domestic and international evidence against this.’

ASH was also aware that in other countries the hospitality trade and the tobacco industry had successfully collaborated to resist anti-smoking legislation and support a voluntary approach instead; so another key strand to the campaign was to drive a wedge between these two powerful vested interests. Campaigners discovered that if a voluntary approach to smoke-free regulation was no longer on offer, the second-best options of each industry were different. The hospitality sector preferred nationally applicable legislation, as this would give a level playing field to geographically dispersed hotel and restaurant chains, and better protection against litigation. The tobacco lobby, by contrast, would rather have legislation that would permit local variation, which would be easier to fight location by location. The Labour government, meanwhile, had made clear that if a voluntary approach was off the cards, it would prefer locally applicable legislation. This prompted the hospitality trade to fight harder for its approach and made it easier for ASH to foment a split between it and the tobacco industry. Further pressure was put on employers by the threat of staff making claims under health and safety law. More than 50 such cases were begun, and although none made it to court before the smoking ban was passed, they had the desired effect on the debate.

There were still obstacles, not least opposition from the secretary of state for health at the time, former MP John (later Lord) Reid, who was an ex-smoker. Reid did not want legislation, and even when he accepted that a ban was inevitable he proposed exempting pubs and clubs that did not serve food. This proposal was in Labour’s general election manifesto in 2005.⁹ But the ASH campaign was given a shot in the arm by an extraordinary comment from Reid at a public meeting:¹⁰

“I just do not think that the worst problem on our sink estates by any means is smoking but that it is an obsession of the middle classes. What enjoyment does a 21-year-old mother of three living in a council sink estate get? The only enjoyment sometimes they have is to have a cigarette.”

The resulting media furore over Reid’s clumsy assertion, combined with declarations about the risks to health by, among others, Sir Liam Donaldson, the government’s chief medical officer at the time, helped to split the Parliamentary Labour Party and shore up support for the anti-smoking lobby.¹¹ The charity coalition led by ASH convinced the Conservatives to allow a free vote on the issue by their MPs, and on St Valentine’s Day in February 2006, Parliament voted by a majority of 200 to pass the Health Bill.¹² The smoking ban came into effect on 1 July 2007. When ASH analysed the government’s own impact assessment and concluded that more than 600,000 people would quit smoking as a result of the new law, it declared it to be ‘the single biggest public health gain since the introduction of the National Health Service’.¹³

Deborah Arnott, chief executive of ASH, wrote about the charity’s tactics in The Guardian newspaper after the law was changed:¹⁴

Campaigning of this kind is literally a confidence trick. The appearance of confidence both creates confidence and demoralises the opposition. The week before the free vote, we made sure the government got the message that we knew we were going to win and it would be better for them to be on the winning side.

In the event, an overwhelming 91% of Labour MPs who voted came out against the position on which the party had fought the election two years earlier.¹⁵ Barron says the contribution from ASH and other charities was crucial to getting the legislation passed:

“The story that was not told at the time was that the charities were rallying their supporters and sending them to their MPs’ constituency surgeries to ask them if they would vote in favour of a comprehensive ban. This was vital information, as we knew what was likely to happen when the actual vote came along in Parliament – we knew we would probably win the first vote. That in the end was what got us the numbers and got us the ban.”

ASH also acted as the secretariat to the all-party parliamentary group on smoking and health and organised a visit by the health select committee of MPs to Dublin to see how the ban already enacted in the Irish Republic was working in practice. Arnott said the campaign went from nowhere to victory in a very short time. ‘Some ideas reach a point at which their time has come,’ she wrote. ‘But some will also often need a vigorous campaign before politicians notice the obvious.’

But ASH wasn’t finished yet. In 2008 the charity published a report reviewing the progress of controls on tobacco and calling for a new law prohibiting retailers from displaying tobacco products, and outlawing the sale of cigarettes and tobacco from vending machines.¹⁶ The report also called for the removal of all colours, corporate logos, branding and positive images from tobacco packaging. Within a year, the Health Act 2009 brought in the ban on vending machines, effective from October 2011, and on the display of tobacco products in shops in England, Wales and Northern Ireland. ASH and its coalition partners also campaigned for standardised packaging, which was made compulsory by the Children and Families Act 2014.¹⁷ This not only forced tobacco companies to sell their products in packets showing alarming images such as diseased lungs or children wearing oxygen masks, but also outlawed the sale of tobacco in small quantities. After May 2017, smokers were permitted to buy cigarettes only in packs of 20 or larger, and tobacco in 30-gram pouches. Menthol-flavoured cigarettes were banned from May 2020.

These new laws, promoted so effectively by one small charity, have been accompanied by a substantial fall in smoking, which is generally acknowledged to be one of the biggest causes of ill-health. An analysis of hospital admissions published in the British Medical Journal in 2010 showed that in the first year after the ban, emergency admissions for heart attacks in England fell by 1,200, saving the NHS more than £8 million.¹⁸ According to Public Health England, 14.7% of adults in England were smokers in 2018, down from 19.8% in 2011.¹⁹ In 2000, 26.8% of adults aged 16 and over had been smokers.²⁰

Another campaign that played a part in changing public opinion in the build-up to the ban on smoking in public places was an unmissable TV and poster campaign by the BHF in 2003. It showed repulsive images of fat dripping from the end of a cigarette and fatty deposits being squeezed out of a human artery. It received extensive media coverage, and traffic to the BHF website spiked by 78%.²¹ Another BHF advert featured two young men in a pub looking at a smiling woman smoking a cigarette. “Ugh,” remarks one. “Like kissing an old ashtray.”

Alcohol campaigns

When the first national coronavirus lockdown began in March 2020, the volume of sales in alcohol shops shot up by a third, according to the Office for National Statistics.²² By September, however, it was clear that the increase in retail sales did not outweigh the loss of sales in pubs and restaurants: a total of 1.3 billion litres were sold in the four months to 11 July, compared with 2 billion litres in the same period the previous year.²³ But the charity Alcohol Change UK published a survey in April showing that 20% – an estimated 8.6 million adults – of drinkers were drinking more frequently and 15% of them were drinking more in each session.²⁴ Three months later the charity repeated the research and found that heavier drinking by a minority was continuing even though the first lockdown was easing.²⁵

At the same time the charity also reported a fourfold increase in visits to its website, which has advice and information about how to keep drinking under control and where to find help and support. It also referred to research showing a link between increases in alcohol-related hospital admissions and decreases in spending on alcohol services since 2012. “By properly funding alcohol treatment services the government can save the NHS money, aid the national recovery effort and save lives,” said Dr Richard Piper, chief executive of the charity.

Like many charities, Alcohol Change UK thus led the way during a national emergency in analysing the situation in its area of expertise, coordinating help and support for citizens and arguing for policy change by the government. In doing so it was building on nearly a decade of campaigns by both Alcohol Concern (which combined with Alcohol Research UK in 2017 to form Alcohol Change UK) and CRUK. Dryathlon, which involved giving up alcohol for January, was launched by CRUK in 2013; it was primarily a fundraising campaign, but it also reduced supporters’ consumption of alcohol, which is a known cause of some cancers. In its first three years 170,000 ‘Dryathletes’ raised more than £17 million.²⁶ Dry January, by contrast, was devised by Alcohol Concern as a public health campaign intended to counteract Christmas and new year binge drinking and the growing consumption of alcohol by the British. One study of global drug use suggested that Britons got drunk more often than the inhabitants of any other country in the world.²⁷

The idea for Dry January came from one woman, Emily Robinson, who decided to run a half-marathon in February 2011.²⁸ She found the training hard and decided to see if giving up drinking would help. She noticed not only that she slept better, lost weight and had more energy, but also that everyone wanted to talk to her about what it was like to give up drinking for a while. One year later, Robinson joined the staff at Alcohol Concern and the idea for Dry January 2013 was born.

In that year, 4,350 people signed up. The following year more than 17,000 reported that they had stopped drinking for the month.²⁹ A study by the University of Sussex six months later found that of 900 abstainers surveyed, 72% had kept harmful drinking down afterwards and 4% were still not drinking.³⁰ Alcohol Concern struck up a partnership with Public Health England, and the government contributed £500,000 to Dry January in 2015, funding the campaign’s first radio advertisements.³¹ That year, 50,000 people gave up alcohol for the month, and in 2017 a YouGov survey found that four million had taken part.³² Although Dry January did not start out as a fundraising event, several other charities joined the campaign as fundraising partners, encouraging supporters to take part and raise sponsorship. The success of Dry January and Dryathlon prompted Macmillan Cancer Support to create its own alcohol-abstinence fundraising event, Go Sober for October, in 2014.

Care of the mentally ill

Charities also led the way during the coronavirus pandemic in identifying its damaging effects on mental health, providing help and support and arguing for improved services. Two months after the first lockdown in March 2020, the Centre for Mental Health – a charity focused on research and policy – published a study estimating that 500,000 more people in the UK would suffer from depression and other mental health problems as a result of isolation, fear, grief, boredom and job insecurity in the expected recession.³³ It called for a continued financial safety net, government advice to businesses and institutions and targeted support for former COVID-19 hospital patients and health workers. Mind – the new name for the charity formed when three pioneering organisations merged in 1946 to become the National Association for Mental Health – published a survey showing that 65% of people with experience of mental health problems said their mental health was getting worse, and created a section of its website with comprehensive practical advice on improving mental well-being.³⁴

The attention given to mental health during the pandemic owes much to increased public awareness and sensitivity about the subject in the 21st century. This was partly the result of Time to Change, a 15-year campaign by Mind and Rethink Mental Illness, another charity, to change attitudes. The treatment of those with mental illness had improved enormously since the 18th century, when people could pay to watch the disturbed behaviour of the patients in ‘bedlam’– the Bethlem Royal Hospital, located until 1936 in the grand, colonnaded building which is now the Imperial War Museum in London. In Victorian times the attitude to mental illness was more humane, but treatment was based in large asylums with strict regimes which remained the norm well into the 20th century.

In the 1970s, however, the government was persuaded to adopt a policy of ‘care in the community’. This involved closing many of the big asylums and arranging for people to live independently, with psychiatric supervision if necessary, or to be cared for in smaller units and hostels. But care in the community had its failures. In one notorious case in 1992 a newly married man, Jonathan Zito, died after being stabbed in the face on a train platform in London by Christopher Clunis, a young man with a history of mental illness who had been deemed suitable for independent living despite repeated episodes of violent behaviour.³⁵ This and other incidents led to a backlash in the tabloid press, which contended that community-based mental health services were failing to protect the public from what it called ‘schizos’ or ‘psychos’.³⁶

The regular Community Attitudes to Mental Illness (CAMI) surveys, funded by the Department of Health and Social Care (DHSC), revealed fear and discriminatory attitudes.³⁷ When the survey began in 1994, only 42% of a representative sample of the population believed that ‘mental hospitals are an outdated means of treating people with mental illness’. The proportion agreeing that ‘it is frightening to think of people with mental problems living in residential neighbourhoods’ rose from 15% in 1994 to 26% in 1997. In that year 33% also believed that ‘anyone with a history of mental problems should be excluded from public office’.

Mind decided to try to help bring public attitudes into line with public policy. Sue Baker, hired in 1996 to set up the charity’s media department, recalls one memorable double-page tabloid spread featuring pictures of machetes dripping with gore, accompanied by accusations that the government had blood on its hands because of its care in the community policies. She also remembers Mind’s head of policy returning from a visit to the regions and relating how someone had thrown a brick through a young woman’s window when her neighbours discovered she had recently been discharged from a psychiatric hospital: “We were hearing these sorts of things all the time, but for me that was the final straw.”

She organised a project called ‘Not just sticks and stones’, based on interviews with nearly 2,000 people with mental health difficulties who told story after story about being refused jobs, education or housing, losing friends or relationships or being verbally or physically abused.³⁸ The media launch of the results was a great success, securing “wall-to-wall coverage on all the TV stations for 24 hours”, according to Baker, and from then on there was a discernible shift in the tone of press coverage. Subsequent CAMI surveys revealed a softening of public attitudes, albeit marginal, and Baker and her colleagues became convinced that a high-profile, multifaceted campaign to reduce the stigma of mental illness could have a real impact.

After two years in New Zealand working for the Mental Health Foundation there, Baker was rehired in 2007 to lead Time to Change, the joint campaign between Mind and Rethink, financed for four years with a grant of £20 million from Comic Relief and the Big Lottery Fund. The project ran programmes with employers and schools and helped people with experience of mental illness to tell their stories and set up campaign groups; from 2011 the DHSC also contributed funding. The evaluation of Time to Change from 2008 to 2014, based partly on an analysis by the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at King’s College, London, had encouraging results.³⁹ This analysis drew on a survey in which 1,000 people who had used mental health services in the last 12 months were interviewed about their experiences. It said:

Comparing 2014 with 2008, there were significantly fewer experiences of discrimination with respect to friends, family, social life, dating, mental health staff, finding a job, keeping a job, police, education, religious activities, privacy, starting a family, or being shunned. The evaluation also notes a direct correlation between these findings and the Time to Change campaign. When the data from all time points are aggregated, a significant relationship between awareness of Time to Change and each of the outcomes is apparent.

In 2017, Time to Change and the IoPPN also released research showing that reporting of mental health by the print media was more balanced and responsible than before.⁴⁰ This study was based on an analysis of articles on mental illness in 27 local and national newspapers on two randomly selected days of each month during 2016. For the first time since the study had begun in 2008, there were more articles promoting mental health or portraying mental illness in a sympathetic way (50%) than stories that portrayed people with mental illness as a danger or problem to others or as hopeless victims (35%). The remainder were mixed or neutral.

Professor Sir Graham Thornicroft, who leads the team at the IoPPN, credits Time to Change with making a definitive impact on attitudes to mental illness:

“There is no doubt that stigma and discrimination are slowly but steadily decreasing in England. This is against a backdrop where, before Time to Change, they were actually increasing. The team at King’s College has published over 100 scientific papers about stigma since Time to Change began, looking in detail at many aspects of the impact, and we’ve seen how it has improved knowledge, attitudes and behaviours. I do not think that all the stigma reduction in England is due to Time to Change, but I do think it has been the leader in this field and made the major contribution to these forms of social progress.”

The biggest lesson from ten years of Time to Change, says Baker, who went on to become the campaign’s global director, was that it demonstrated the effectiveness of leadership by people with direct personal experience:

“It’s those of us with mental health problems leading change in our communities, workplaces, schools, at a national level – using our mental health issues as an asset, not a deficit. It was because so many people stayed silent for so long that you didn’t realise you sat beside or were managed by or managed someone who had a mental health problem. All of that was hidden because people were so afraid of the consequences of being up-front about it.”

Steve Loft was one such individual. In 2011 he was signed off from his job at Transport for London (TfL) for eight months while being treated for stress and depression. But going back to work was a trial. “It was like there was a big exclusion zone around me – nobody knew what to say to me,” he recalls. “Although I had a good line manager, he did not have a clue about how to deal with someone with a mental health problem.” Loft discovered that TfL had in fact signed the Time to Change pledge two years earlier, and he persuaded the company to set up an intranet site and a peer-support group that by 2019 had nearly 300 members. Time to Change supplied resources and speakers, and Loft became a ‘workplace champion’:

“This is really powerful as it gives people confidence to share their own experiences. I’ve seen a sea-change in attitudes to mental health in the last six years. I go out now and train other champions, and if I had a pound for every time someone said attitudes are changing, I’d be a rich man. I think there is going to come a tipping point. I’m old enough to remember all the things that used to happen with race, but then at some stage people just weren’t prepared any longer to listen to other people talking and acting in a discriminatory way. I still think mental health has got a way to go, but it’s certainly shifted a hell of a lot in those few years, and that’s got a lot to do with those charitable organisations that have worked really hard to change things. Now, when people come back to work at TfL after being off for stress, I’ve noticed that others go and talk to them – they’re not frightened any more. When I was off work, a lot of my problems stemmed from the fact that, as a middle-aged bloke, you just weren’t conditioned to talk about your mental health. But it’s very different now.”

Unfortunately, however, in October 2020 the DHSC declared that it could not continue to fund Time to Change, and the charities that had run it for 15 years reluctantly announced its closure, with a warning that the gains made as a result of the campaign were at risk of sliding backwards.⁴¹ Time to Change ended on 31 March 2021, very likely a direct casualty of the pressures on public spending created by the coronavirus pandemic.

Cervical screening

Other health campaigns by charities may be less high profile than those on smoking or mental health, but they appear regularly. They often form part of the controversies, debates and stories in the media that lead to improvements in official policy or changes in funding decisions. Early in 2018, for example, BBC News reported on a survey of more than 2,000 women which showed that one in four of them did not take up regular invitations to have a smear test, and that the figure was one in three for the 25–35 age group, in which cervical cancer is the most common form of cancer.⁴² The reason women most commonly cited for not booking a test was embarrassment about a stranger examining their bodies. The research had clear implications for social policy and clinical practice, however, and Steve Brine MP, then the junior health minister responsible for cancer, pledged to support a campaign to reassure women and improve the level of response to invitations to smear tests, which are offered every three years to women aged between 25 and 49 and every five years to those between 50 and 64.

Who carried out and publicised the survey in question? It was a small charity called Jo’s Cervical Cancer Trust, founded in 2000 by a London businessman, James Maxwell, after the death from cervical cancer at the age of 40 of his wife, Jo. She had wanted other women to have what she had missed: better screening and diagnosis, more medical information, the confidence to challenge doctors, and communication with others suffering from the disease.

In the following 20 years the Trust expanded and made a significant contribution to advances in the prevention and treatment of cervical cancer, including the introduction in 2008 of a programme of vaccination for girls in school against human papilloma virus, the cause of nearly all cases of the disease. In 2020 the Trust was employing about 25 people, running a comprehensive website, campaigning for better prevention and treatment, providing detailed medical information and offering emotional and practical support to women. Its annual income in 2019 of £1.6 million was a mixture of voluntary donations, grants from the DHSC and the Scottish Government, and gifts in kind such as advertising on Google.

Changing people’s behaviour is rarely easy, especially when it involves asking them to re-examine deep-seated attitudes or to stop doing something they find pleasurable or convenient. The examples in this chapter show that it can be done through a combination of information, persuasion and legislation, and that charities have played a key part in both large- and smaller-scale measures to produce change affecting people’s physical and mental health. The next chapter examines the involvement of charities in campaigns about something just as fundamental and often more controversial – human rights and equality.