What is advocacy?
Effective advocacy improves decision-making within systems and organisations. It often starts by listening to those affected by corporate decisions, then gathering data and finally suggesting better solutions. This is different from activism, where an individual is trying to change the system often by direct action.
Within our health systems we should be advocates for the families we see to help them improve the conditions in which they live, work and play, as well as the services they use.
The opening questions in health advocacy are ‘what is it that you want to change’ and ‘why now?’ The answers should produce a clear focused goal with precise and tangible outcomes. Asking further questions that consider the case for and against action are also essential to then develop the right strategy.
There are a number of components to advocacy in the NHS:1
- Information: Relevant, powerful data is the first tool of successful advocacy. What is your key message? How does the data support it? What are the potential benefits?
- Patient stories: These help to put the data into context. Rosamund Kissi-Debrah is raising awareness about air pollution after the tragic death of her daughter Ella, the first person in the world with air pollution documented as a cause of death. Cases like Ella’s help to show the real world impact of the issues being discussed, which can sometimes seem abstract.
- Leverage: This is calling on stronger parties, those with more influence, to act on behalf of those who are weaker, leveraging that strong voice to achieve an aim. Creating alliances with others can be beneficial.
- Accountability: Organisations and governments can be held to account when promises, policies and legislation have not been achieved or enforced, or stated targets have not been met.
It is also important to review and reflect on your approach to consider lessons learned for the next time.
The right person: At whatever level or organisation you want to influence, a lot of advocacy is about finding the right person. This is the person who can get you into the right meetings and has an interest in what you are passionate about. Keep talking to people in your organisation and eventually you will find that key individual.
Levels of advocacy
As a healthcare professional you have a strong voice that can be used in a number of situations to advocate for our patients with regards to climate change and inequality.
1. For individual patients
Educating patients and families about the impact of climate on their specific health condition, such as air pollution and asthma, or poor housing and mental health can facilitate the finding of solutions to mitigate those impacts, such as changing the route to school and improving indoor air quality. We can also help patients with letters of support when looking for better housing or applying for insulation. Click to open, and copy into your letterhead or email template, or download a Microsoft Word version below.
- Template for a letter of support for new housing or improvements
Dear housing officer / housing association / landlord/ whom it may concern
I have asked XXX’s family to this pass this letter on to you as I have concerns that their current housing situation is having a negative impact on their health.
XXX has a diagnosis of asthma/wheeze. They also have severe allergic rhinitis and eczema. It is my belief that the family’s current housing situation is significantly contributing to their health condition(s) and the amount of medication they are requiring to control them.
The National Review of Asthma Deaths published in 2014 and 2018 identify a number of risk factors for asthma death and below I will explain how several of these and other factors are relevant to XXX asthma and other health needs.
Critically, it was found that over 90% of deaths in children could have been prevented if the pre-existing risk factors had been identified and addressed by the agencies already involved in the child’s care, including health, education, social care and other Local Authority bodies.
- The property is overcrowded. This will increase dust mites which will cause more inflammation to the airways due to an allergic response causing allergic rhinitis. This will increase the risk of severe exacerbations of asthma/wheeze. Overcrowding also increases the likelihood of catching viral illnesses, which is a trigger for asthma/wheeze.
- There is significant damp and mould which will cause airway inflammation due to breathing in mould spores. This will exacerbate asthma/wheeze and cause these children to have more exacerbations: www.asthma.org.uk/advice/triggers/moulds-and-fungi
- Reducing humidity in the home environment is essential. Works should be undertaken to correct any structural issues causing damp, including improving ventilation. A dehumidifier may be needed.
- People smoke near the property. The family are able to smell smoke within their home which is a trigger for XXX‘s asthma causing an increased likelihood of an exacerbation and a severe attack.
- Asthma can be triggered by stress and anxiety. They have expressed that their living environment is stressful which will exacerbate their asthma causing more attacks.
We are very concerned that this property is contributing to this child’s asthma/wheeze episodes, increasing the frequency of their attacks, which could lead to a severe life threatening asthma attack. Due to their ongoing exposure to environmental triggers in their home, we are unable to adequately control their symptoms with the medication we are prescribing.
XXX has a right to live in a property that is not detrimental to their health. Please provide this family with any support within your power to assist them with improving their current house or re-banding for new accommodation.
If repairs to the property are felt to be insufficient to protect this child’s health (e.g. in circumstances where overcrowding is an ongoing issue), re-housing and their family should be prioritised in order to protect ’s future health and well-being. New accommodation should be:
- Free from damp and mould, well ventilated
- Has hard-flooring and blinds rather than carpet and curtains
- Does not require to have bunk-beds in their room, as these are particularly problematic in house dust mite allergy
- Has its’ own washing machine so bedding can be easily washed at 60C
Section 11 of the Landlord and Tenant Act 1985 states that landlords have a duty to 'keep in repair: the structure and exterior of the dwelling, including drains, gutters, and external pipes. To keep in repair and proper working order the instillation in the dwelling of the supply or water, gas, electricity and for sanitation. This includes drains, sink, baths and sanitary convenience and to keep in repair and proper working order the installation in the dwelling for space heating and heating water'.
The Homes Act, March 2019 ensures tenants can expect their homes ‘to be fit for human habitation’, which means that it's safe, healthy and free from things that could cause anyone in the household serious harm. This Act also puts obligation on the landlord to ensure tenants are able to ventilate the property effectively.
I have provided the family with details of the following organisations who can help support them. I have made them aware that they can take this further using section 89 of the Environmental Act 1990.
Information and support: www.england.shelter.org.uk
How to make a complaint: www.housing-ombudsman.org.uk
Legal advice, no win no fee: www.tenantsadvice.co.uk
Please do not hesitate to contact us for additional information if this would be helpful. We
look forward to your response and support.
[Developed by Royal London Hospital, Barts Health, Queen Mary University of London, and North East London Health & Care Partnership]
2. Within your local organisation
How is your trust doing? Are there areas where they can be doing better? Taking local data to your board with local patient stories could be the catalyst required. You can find more information and resources on climate change for health professionals on this website. Introducing some of these measures to your own department, possibly using quality improvement methodology, may create some data and possibly some stories that you can use to spread that change across your trust.
3. At regional level
Your local council will have influence over town planning including roads and transport, housing developments and green space access. The RCPCH Climate Change Working Group has produced a toolkit for paediatricians approaching their local council about air pollution (PDF).
Friends of the Earth has resources on climate action plans for parish and town councils as do the Local Government Association for England. You can contact your local councillor and ask about what they are doing about mitigating and adapting against climate change and its unequal impact on children and young people’s health.
You can act as advocates at a regional level and support action in your local area. We give some options for regional level advocacy within each UK nation:
In England, integrated care systems should have a children’s lead that you can approach. They are supposed to be delivering the Core20Plus5 for children and young people, the NHSE’s approach to reducing health inequalities focused on children and young people, which includes asthma and mental health as key clinical areas of focus. Both of these are significantly affected by climate change so the policy could be used to hold them accountable.
They should also have a CYP strategy and a five year forward plan. Does climate change feature?
If you are based in England, you could also become involved in the RCPCH Ambassador programme, advocating on behalf of CYP within your local area.
In Scotland, there are 31 health and social care partnerships (HSCS) who aim to deliver better health and wellbeing outcomes with a community-based approach. This is carried out via a Lead Agency agreement (Highland & NHS Highland) or an Integrated Joint Board (all other areas).
This health and social care integration has created a unique set of arrangements, with all partnerships becoming responsible for adult social care, adult primary health care and unscheduled adult hospital care. However, only some HSCS are responsible for children’s health and social care services. In some areas, these powers have remained with the local authority and / or health board.
However, all Health Boards, Local Authorities and Integrated Authorities must work together to deliver on the Scottish Government’s National Health and Wellbeing Outcomes, that includes contributions to reduce health inequalities.
You can find out more about your local HSCS and its strategic plans to achieve the national outcomes.
If you would like to join RCPCH Scotland in advocating on behalf of CYP, please get in touch via email@example.com.
Health boards in Wales work as key partners with their Regional Partnership Boards (RPBs) to ensure an integrated and coherent approach to planning. NHS Wales recognises it has a significant contribution to make towards the ‘team Wales’ target of a net zero public sector. To stimulate engagement and action across all parts of NHS Wales, the first initiative within this Delivery Plan provides the commitment to address the Climate Emergency.
NHS Wales aims to show leadership and commitment to deliver the Decarbonisation Delivery Plan in order to address the Climate Emergency for Wales as declared by Welsh Government and the Senedd. The NHS Wales requirements under the Well-being of Future Generations (Wales) Act 2015 will ensure that the climate is considered at an everyday decision-making level.
If you would like to join RCPCH Wales in advocating on behalf of CYP, please get in touch via firstname.lastname@example.org.
- Northern Ireland
In Northern Ireland, the developing regional Integrated Care system will be supported by five Area Integrated Partnership Boards advising on demand and commissioning for health and care more closely to the communities they serve. It is hoped that these structures will be in place in NI by April 2024 following a pilot in 2023.
It is also hoped a Green Health and Social Care NI Strategy will be taken forward soon. Paediatricians with an interest may wish to engage the Public Health Agency (PHA) to discuss the development of a Green Health and Social Care Strategy further.
If you would like to join RCPCH Northern Ireland in advocating on behalf of CYP, please get in touch via via email@example.com.
- Use data and evidence as tools to support your case, for example research and familiarise yourself with your local air quality statistics.
- Ask out if there's an existing local strategy or initiative in place to address climate change which considers the impact on child health inequalities. If not - what can be done to start the process?
- Check whether children and young people are being consulted in the process of any policy or service development. If not, how could this be introduced and committed to?
4. At a national level
To complement advocacy at a local and regional level, we recommend building a relationship with your MP to raise these issues at a national level. Your MP can help build support for policy change within their party and the Government, for example campaigning in Parliament for a child rights impact assessment to be placed on a statutory footing or by directly asking the Government what assessment they have made of the impact of climate change policies on children’s health.
The College plans to engage parliamentarians on climate change and health inequalities through a policy roundtable on 12 December. You can invite your MP to this event through our e-action - it takes just a few minutes.
You can also write to your MP directly and/or join future letter writing campaigns run by RCPCH to write to your MP as they occur.
Combining your voice with others can be very powerful. The College acknowledges that and joins with a range of other organisations on particular issues and encourages its members to join together as well. For example, think about whether you can write jointly with colleagues to your local MP about an issue. They might be more willing to meet with a group of child health professionals than just one and the College would be happy to support such a meeting.
- Sign up to the RCPCH Climate Change eBulletin and the newsletter from the Health Alliance on Climate Change
- Marmot climate and equity (PDF)
- The Centre for Sustainable Healthcare - and education and training
- Greener NHS (england.nhs.uk) -
- Simon Sinek. TED talk on How great leaders inspire action
- Racha Fadlallah using narratives to impact health policy-making: a systematic review. Health research policy and systems. volume 17 article number 26 (2019)
- Plan International, Global Education First Advocacy Toolkit
- World Health Organisation. A practical guide to successful advocacy. 2006.
- Chapman S. Advocacy for public health: a primer. J Epidemiol Community Health 2004;58:361–365. doi: 10.1136/jech.2003.018051 2004
- Promoting health advocacy guide for health professionals. International Council of Nurses. 2008.
- The British Institute of Human Rights Human Rights for Community Groups Raising a human rights issue: tips and tools. Bringing rights to life. 2012.
- D’Eath M, Barry MM, Sixsmith J. A rapid evidence review of health advocacy for communicable diseases. Stockholm: ECDC; 2014.
- MIND. The Mind guide to advocacy. 2010.
- Advocating for children's health: a US and UK perspective. WATERSTON T., TONNIGES T,
- Advocacy and the paediatrician. Waterston T., Haroon S.
- Teaching and learning about advocacy. Waterston T.
- The role of advocacy in promoting better child health. Devakumar D., Spencer N., Waterston T.
- Exploring the scope for advocacy by paediatricians. Rudolf M. et al
- Talking to patients and families about air pollution
- 1Keck, Margaret E.; Sikkink, Kathryn (1998). Activists beyond Borders Advocacy Networks in International Politics. Cornell University Press. p. 16. ISBN 978-0-8014-7129-2.