Better Health For All

The demand for healthcare is growing and the NHS is facing the challenge of treating patients with multiple long-term conditions in high-cost settings, with limited resource set aside for prevention.  To have any hope of reversing this trend, hospitals need to embed prevention into their strategies to address the growing demand for health services driven by a population growth, ageing and health inequalities.  Doctors have an important role in addressing health inequalities, by advocating for change in healthcare. 

An ageing population with multiple long-term conditions highlights the need for training tomorrow’s doctors with skills such as generalism, leadership and an interprofessional approach to patientcare.  COVID-19 has emphasised the significance of public health as a speciality and rekindled wider interest in health inequalities(1).

Whilst population health (public health) has become a prominent topic in undergraduate medical education, there is variability in the design and delivery of the topic.  Public health educators have challenges with integrating this topic into the undergraduate curriculum (both teaching and assessments).  It is often taught in isolation, without adequate integration into other aspects of curriculum, yet when integrated it can be overlooked or ignored by both students and tutors prioritising the immediate clinical aspects over broader conceptual issues.  Students seem to perceive public health to be just statistics and struggle to appreciate its relevance to their developing clinical practice.  However, there are signs of change in the long term perspective on medical education and training, which should be  to the advantage of public health – such as the NHS Long Term Plan(2)  and the GMC Outcomes for Graduates (3).

“Newly qualified doctors must be able to recognise sociological factors that contribute to illness, the course of the disease and the success of treatment and apply these to the care of patients − including issues relating to health inequalities and the social determinants of health, the links between occupation and health, and the effects of poverty and affluence.” (3)

We need to be conscious of recently proposed changes in medical education such as the 4-year undergraduate degree, apprenticeships and the Medical Licensing Assessment (MLA) which will begin to be rolled out in 2025. A compressed curriculum, and “teaching to the test” both risk squeezing out elements which are seen as non-core (4).

The recent moves to pool resources across primary, secondary and community sectors marks an unprecedented opportunity to take a population health management approach by pooling to tackle health inequalities.  This allows medical schools to explore collaboration with the Integrated Care Boards (ICBs, or equivalents) and develop multiprofessional system clinical leaders.

“Newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice.” (3)

Medical schools (as part of universities) are socially accountable to the communities they serve.  As anchor institutions, NHS and universities play an important role in the local society.  Some medical schools are already exploring community immersive opportunities for students, so they can gain hands on experience in health leadership, prevention, population health management and appreciate an interprofessional approach to tackling health inequalities. This approach should be encouraged and “scaled up”.

A flipped classroom approach to public health teaching along with experiential learning can provide medical students with patient-focused learning opportunities.  Further, to implement a competency-based public health curriculum, medical educators need to take on the role of mentors, supervisors and role models to create a supportive teaching environment facilitating the application of public health in clinical decisions.  This also requires institutional support and investment of resources.

Dr Bharathy Kumaravel and Dr Ellie Hothersall
Co-Chairs, FPH Public Health Educators in Medical Schools Special Interest Group

References

1.             Rodrigues V, Hothersall E, Davies M. Public Health Education in Medical Schools – The Impact of the COVID-19 Pandemic. J Med Educ Res [Internet]. 2021 Sep 2 [cited 2024 Apr 16];1(1). Available from: http://www.ubplj.org/index.php/jmer/article/view/1926

2.             NHS England. NHS Long Term Workforce PLan [Internet]. 2023. Available from: https://www.england.nhs.uk/long-read/nhs-long-term-workforce-plan-2/

3.             GMC-Outcomes for graduates [Internet]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/outcomes-for-graduates/outcomes-for-graduates

4.             Harden RM. Five myths and the case against a European or national licensing examination. Med Teach. 2009 Jan;31(3):217–20.

The Adult Social Care SIG and the Musculoskeletal SIG got together to explore where our agendas overlap, using as a starting point the 2023 Chief Medical Officer for England’s report on population health in an ageing society. Its focuses on maintaining independence and delaying disease onset provide useful themes for our two-part blog.

We were curious about musculoskeletal (MSK) conditions and their impact on adult social care (ASC), and how we as public health professionals might raise awareness of both the challenges and the potential solutions.

The likelihood of having an MSK condition increases with age. In the UK, just under 1 in 3 in people aged 35-44 have an MSK condition. This increases to almost 2 in 3 people for those aged 65 and over.  

MSK conditions can have a serious impact on people’s daily lives and are one of the leading causes of morbidity. 21% of years lived with a disability are attributed to MSK conditions in the UK.

As well as morbidity due to MSK conditions themselves, these problems often co-exist with others. Among people aged 45 and over living with a long-term condition, more than three out of 10 also have an MSK condition. And the co-morbidity is often with a mental health condition. Primary care data in England reveals there is a 40% increase in the odds of a self-reported mental health condition among people with an MSK condition.

With the over 65 population in England and Wales set to rise from 11 million to 13 million in the next ten years, the burden of these issues are only going to increase, and will have a significant impact on health care and social care systems.  

Given the prevalence statistics above, we can imagine the impact on individuals in their daily lives and on health care systems, but what about adult social care? The answer is – it’s very hard to quantify.

A diverse range of adult social care services are offered by local authorities. However, there is little specific data about the services that people with musculoskeletal conditions access, or those that are provided, at either a local or national level.

However, some recent research indicates that adults with chronic MSK pain report significant social care use. In the study of over 900 participants across the UK with chronic pain, 54% received formal social care support and 74% received informal support. Authors do not report how many participants stated that they needed help. The study also found that the likelihood of social care being provided increased by 50% for each additional chronic disease reported. The authors point out that social care use is ‘frequently not considered when assessing the overall cost (both financial and societal) of MSK morbidity’, and they conclude that understanding the relationship between MSK diseases and social care may allow better design of social care services in this context, as well as opportunities to develop prevention strategies.

We would argue that in the current context of massively stretched adult social care budgets and rising thresholds for eligibility, we are missing an understanding of the relationship between population MSK need, ‘what works’ to prevent and improve these conditions in the social care context, and the design of programmes of support.

Reaching a place where we understand these dynamics and are able to formulate prevention strategies may be undermined by a number of features of adult social care which perhaps set it apart from health care systems. Research published in 2019, which sought to develop a framework for evaluation for prevention in adult social care prevention efforts, found challenges in data collection including a lack of longitudinal data and a short-term approach to evaluation. Authors suggested there may also be a lack of appetite to invest in data gathering and analytical capabilities, particularly in times of budget restrictions.

Public health data on musculoskeletal health is patchy, at least in England, with the latest prevalence figures in Fingertips being from 2012, and 2016/17. The limitations of public health data – and in fact the lack of recognition of MSK conditions as a public health priority – had been noted in 2011 in the England CMO’s report.

So, in concluding this first part of our joint blog, the impact of MSK conditions on adult social care will no doubt be great, but being able to say more than that is hampered by a lack of information. This has a significant impact on our ability to put in place prevention strategies and evidence-based interventions to address the needs of this population. We haven’t looked exhaustively at all the literature, including grey literature produced in the four UK nations, so please do get in touch with us if you can shed light on any of the issues highlighted.

The second part of our joint blog will focus on innovative community-focused programmes for responding to and preventing MSK conditions, and some ideas for how public health professionals can influence health care and social care systems to make a difference, including addressing the lack of data available to understand the needs of this population.

Sebastian Baugh, Eugenia Cronin, Benjamin Ellis & Elaine Rashbrook

Comments to: benjamin.ellis@nhs.net and elaine.rashbrook@dhsc.gov.uk

The Faculty of Public Health is a champion for the very people who form the backbone of our nation’s health and wellbeing – our public health professionals. Yet, we are concerned about the risk of a slowly emerging yet persistent challenge – the widening of pay inequities for public health specialists working within the UK public health system.

This is not simply a matter of numbers and spreadsheets. It is a moral failing, an injustice that undermines the very foundation of equity we strive to create in public health. It’s about recognising the worth of every individual, regardless of their demographic characteristics, level, or site of employment.

Consider the facts: women, who now make up a significant portion of our public health workforce, often face pay gaps compared to their male counterparts. The picture worsens for ethnic minorities, where the disparities become even more pronounced.  Pay differences for public health specialists are also emerging dependent upon employer, UK nation and region of residence, and between whether working at national, regional or local levels in the system. Pay equity isn’t just about fairness; it’s about talent retention, recruitment, and ultimately, the effectiveness of our public health system.

When we undervalue a group of professionals, we send a damaging message: their contributions are less important, their expertise less valuable. This not only demotivates individuals but also deters future generations from pursuing careers in public health, further exacerbating workforce shortages. But let us be clear: this is not about pitting groups against each other. It’s about recognising the inherent value in each individual and ensuring that their contributions are rewarded fairly. It’s about building a public health system that reflects the diversity it serves, where talent is recognised and nurtured, regardless of background.

How did we get here?

The Faculty has for many years been concerned by the significant differences in pay and terms and conditions of service between people registered by the GMC and UKPHR. This appears inequitable when the higher specialist training of people registered with the GMC or UKPHR is identical. There are also many differences in the Terms and Conditions of Service (TCS) of doctors and non-doctors e.g. relating to out of hours work, and only doctors being eligible for clinical impact (formerly excellence) awards.

The Faculty is not a trade union, but has taken an active interest in this issue, particularly given our role in supporting the appointment of all Consultants and Directors of Public Health in the country through Advisory Appointment Committees (AACs). Though the Faculty’s dataset on applicants for Consultant posts utilising AACs for Scotland is not as large as it is in the rest of the UK, the Faculty will publish some of our intelligence on advertised pay and expects to provide more published information on AACs in 2024.

The NHS decided many years ago that only medically qualified persons could be paid on medical TCS and that non-medically qualified public health consultants should be paid on a broadly equivalent Agenda for Change band. In Wales, an exercise was carried out a few years ago which determined that the appropriate banding for UKPHR registrants was Band 9 which is similar to the pay of medical Consultants, although if you spent your whole Consultant career in Wales, the lifetime earnings of the medically registered Consultant would still be significantly higher than that of a UKPHR registered Consultant. In Scotland, England and Northern Ireland, non-medically qualified Consultants in Public Health are usually banded as 8d and earn considerably less than their medical colleagues.

What’s being done?

The Faculty has pressed for a similar grading of Agenda for Change Consultant posts exercise to be carried in the rest of the UK as it was in Wales. So far this request has resulted in an in-principle commitment from OHID/DHSC to undertake a grading review. Scotland has not yet responded to the request. One can speculate that the reticence to follow the Welsh example may be in part because the relevant employers are financially challenged and have decided not to take action which could lead to a significant increase to their wage bill.  

The Faculty is also exploring, with the help of the BMA, whether there is a potentially strong case under equal pay legislation to address the unequal pay offered to registrants of the GMC and UKPHR . A request for information under the Freedom of Information regulations was made by the BMA in 2023. A successful challenge to the current pay structure would need to demonstrate discrimination on the basis of a protected characteristic e.g. gender. 

Given the growing numbers of consultants employed by Local Authorities (LAs) in England, the vast majority of LAs currently do not offer medical terms and conditions of service to GMC registrants, which has led to a situation where Consultant salaries appear almost certainly lower than those in OHID, UKHSA and the NHS. Whilst the Faculty only has data on advertised rather than actual salaries, we do know with certainty that a higher proportion of GMC registrants work for OHID, UKHSA and the NHS, and a factor in their choice of employer is the better pay and TCS offered.

Though it may be equitable that Local Authorities pay consultants the same salary irrespective of background, it is unfair that the pay offered is significantly lower than that offered to consultants employed in the NHS, OHID and UKHSA. The Faculty is keen to work with our Local Authority colleagues to raise concerns about how inequity in pay is distorting the labour market for public health Consultants.

With respect to the UK government, a case has been made to the Secretary of State that funding for pay awards for the NHS are not routinely made available to non-NHS employers, even though the COVID-19 pandemic demonstrated beyond doubt that public health is an essential part of a national health service even when it is not part of ‘the’ NHS. If this issue is not addressed it is likely to lead to even wider disparities between public health staff employed by the NHS and other employers.  

The Faculty is producing a long-term specialist public health workforce strategy (2023-30) and is seeking cross-party political support for the strategy which includes a commitment to pay equity.

Conclusions

In summary, addressing pay inequities is not just the right thing to do; it’s also the smart thing to do. It strengthens our workforce, fosters innovation, and ensures that public health reaches every corner of our society. This is not just a policy issue; it’s a call to action, and the Faculty is committed to addressing Consultant pay inequity in the UK on behalf of our members.

We, as a public health community, need to work together. We need to engage in open dialogue, conduct thorough research, and advocate for policies that promote pay equity. We need to hold ourselves and our institutions accountable for ensuring fair and equitable treatment of all professionals. Working with resolve, partnership, and a shared commitment to justice, we can create a public health system where everyone is valued, everyone is empowered, and everyone contributes to a healthier, more equitable society. Let us rise to the challenge and build a public health system worthy of the dedication and expertise of its professionals.

Professor Kevin Fenton CBE FFPH
FPH President

Dr. Ellis Friedman
FPH Registrar

From pandemics to climate change, the complexities of our world demand a new breed of leader – one who thrives in the face of uncertainty and orchestrates collective action amidst chaos. Let’s explore what this might mean for those of us in public health.

As I travel around the country meeting fellow public health colleagues, I am consistently struck by one consistent message: We are indeed living in interesting and complex times. Whether working within the context of rising pressures on health services, rising tides of infectious and chronic diseases, widening health inequalities, growing poverty, shrinking budgets accelerated by the cost of living crisis, public health is becoming more challenging and the communities we serve are in greater need.

The truth is that we are standing at a pivotal juncture. Our interconnected systems, once seemingly predictable, now are defined by complexity. Pandemics, the cost-of-living crisis, climate change, and rising inequalities are intersecting to create overlapping and unanticipated challenges. Yet, amidst this uncertainty, a critical opportunity emerges: to forge a new paradigm for public health leadership in complex times, one that transcends traditional models and embraces the intricate realities of our time.

This new leadership paradigm demands a multifaceted lens. It requires us to abandon simplistic narratives and embrace the inherent complexity of our systems. As we learned in the acute phase of the COVID-19 response, linear, top-down and heroic models of leadership were unable to effectively respond to the complexities of a rapidly emerging, unknown disease affecting every part of our globally connected society. More recently, the growing realities of child poverty, worklessness due to poor health, and declining economic productivity require different approaches to tackling them. Critical thinking, a systems-level perspective, and a thirst for diverse perspectives become our guiding lights. By understanding the interconnected web of factors shaping our challenges, we can move beyond symptom-based solutions and craft interventions that address the root causes.

Within this increasingly complex environment, equity must be our compass, not a distant aspiration. We cannot afford to be bystanders in the face of health inequalities that scar communities and end lives prematurely. We must champion equity as a core value, dismantling the social, economic, and structural barriers that perpetuate these injustices. I am encouraged by the leadership that public health teams are providing on issues including poverty, homelessness, structural racism, inclusion health among other areas. We bring our commitment to evidence-based action, collaboration, systems leadership, strategy formulation with a resolute focus on delivery. Prioritising resources and interventions for the most vulnerable is not simply a policy choice; it is a moral imperative that demands unwavering commitment.

Collaboration, not isolation, is the key to unlocking transformative solutions. We must foster trust and forge partnerships across sectors and communities. Integrated Care Systems in England, promoting stronger working in place between health and local government, combined with a strong visibility and input of public health experts provide new opportunities for collaboration to improve population health. Public health colleagues are building coalitions for action locally, regionally and nationally recognising that practitioners, clinicians, researchers, community leaders, and importantly, the people we serve, each hold fragments of the solution. By listening with open hearts and minds, we can harness the collective wisdom of this diverse mosaic and co-create interventions that are both effective and sustainable. This was a recurrent lesson in our COVID-19 pandemic response and must now be an enduring legacy.

Agility and adaptability – both professional and organisational – in this ever-changing landscape is essential. We must be nimble, pivoting in response to emerging challenges and opportunities, and be prepared to take full advantage as opportunities arise. Recent opportunities for action on expansion of opt-out HIV testing in emergency departments, tackling youth vaping and progressing smokefree generation legislation in England all highlight the importance of this preparation with agility.  Embracing experimentation, learning from failures, and fostering a culture of innovation within our organisations are essential steps. By staying responsive and open-minded, we can ensure our systems remain relevant and effective in the face of constant flux.

Finally, we must lead with both courage and compassion. We need the courage to challenge the status quo, speak truth to power, and make difficult decisions, even when they are unpopular. Public health teams across the country are leading the difficult necessary conversations on tackling air pollution, climate crisis, structural racism, asylum and migrant health and many other areas deemed politically challenging or difficult given the current funding constraints. Yet, amidst the complexities, we must never lose sight of the human cost of our choices. Leading with empathy, recognising the anxieties and vulnerabilities of those we serve, and demonstrating unwavering commitment to their well-being is the bedrock of effective public health leadership. Ensuring that current and future generations of public health experts have the training, tools and capacity to lead in these new ways will remain a priority for the Faculty of Public Health.

In closing, the paradigm of public health leadership in complexity is not a distant dream. It is the practical toolkit we need to navigate the labyrinth of our present reality. By embracing these principles, we can help to build more resilient health systems, advance health equity, and ultimately, create a world where everyone has the opportunity to thrive. We are not alone in this journey, so let us step forward together, with courage and compassion, to chart a brighter future for public health and the communities we serve.

Professor Kevin Fenton CBE FFPH
FPH President

The escalating crisis of poverty and deepening financial insecurity in the UK represents a significant obstacle to public health and perpetuates health inequalities.

Poverty detrimentally affects health across the lifespan, particularly impacting children, and diminishes life expectancy and healthy life years. These health ramifications reverberate across the NHS, public services, the labour market, the economy, and society as a whole.

To safeguard the well-being of our communities and combat widening health disparities, prioritising the prevention and alleviation of poverty and its health impacts is imperative.

At the Faculty of Public Health (FPH), we are steadfast in our commitment to addressing the health impacts of pervasive levels of poverty that afflict millions annually, a challenge further exacerbated by the current ‘cost of living’ crisis.

The state of UK poverty

The statistics underscore the severity of the situation: In 2021/22, government data revealed that 14.4 million people, including 4.2 million (1 in 3)  children, lived in poverty. It disproportionally affects certain types of household including lone parent families, families with 3 or more children, households with a carer and/or disabled member, and households from many ethnic minority groups. Poverty has deepened, becoming more severe in low income households so that the Joseph Rowntree Foundation (JRF), reported that 3.8 million people experienced destitution in 2022, a figure almost two and a half times higher than in 2017.  

UNICEF reported a 20% increase in child poverty in the UK between 2012 and 2021, surpassing all other EU/OECD countries. The Resolution Foundation forecasts an additional 300,000 people falling into absolute poverty in 2024/5.

A public health crisis

Living in poverty has acute and chronic health effects across the lifespan, driving health inequalities, increasing susceptibility to poor health outcomes, and hindering access to essential resources for well-being. Childhood poverty profoundly impacts cognitive, behavioural, social, and educational development, with enduring repercussions on life prospects and health. The rise in infant and child mortality, particularly among marginalised communities, underscores the urgency of addressing this crisis. The Royal College of Paediatrics and Child Health have said rising child poverty is a major concern and “reducing child poverty must finally become a national priority…this has to be a wake-up call for us all and [we] urge our political leaders to action.” A recent Academy of Medical Sciences report has highlighted the UK’s worsening child health and the impact of child poverty.

The horrific health impacts of living in poverty were starkly brought to light by the tragic case of Awaab Ishak, a 2-year old who died from a severe respiratory condition caused by prolonged exposure to mould. Living in cold and damp homes can result in respiratory problems and other health issues, especially in children, the elderly, and those vulnerable due to pre-existing health conditions.

Inadequate nutrition and hunger lead to a range of health issues, including deficiency-related conditions such as rickets and stunting, both of which have increased in children in recent years. Poor diet due to lack of affordability and access to healthy food leads to obesity and risk of many chronic diseases.

Constantly worrying about having enough money can also lead to chronic stress, anxiety, and depression, and exacerbate existing mental health problems. Poverty also restricts social participation, leading to isolation and loneliness. And both the frequency and impact of health harming behaviours (tobacco, alcohol misuse, gambling) are greatest in low-income households. These are just some of the many negative impacts of poverty on health.

All of this ultimately leads to the increased risk of long-term conditions, reduced healthy life expectancy, and premature mortality, contributing to the life expectancy gap (between the least and most deprived communities) of 10 years for men and 8 years for women, and healthy life expectancy gap of around 19 years. In recent years, both men and women in the most deprived areas have seen their life expectancy decrease.

Taking action

National governments bear responsibility to ensure sufficient income for good health, especially during crises. A comprehensive, national system wide strategy addressing poverty and improving health is imperative. It should encompass bold policies on ensuring secure employment with the real living wage, an adequate safety net for all through the benefit system, and housing reform to ensure affordable quality homes for rent. It will also need to address food and energy security, access to affordable childcare and public transport, and ensure high quality education and skills training for all ages. Furthermore, a fairer distribution of wealth through taxation reforms and innovative solutions like universal basic services must be seriously considered to ensure economic prosperity and improved health outcomes for all.

Public health teams have played a pivotal role in mitigating the cost-of-living crisis locally, collaborating across sectors to provide essential support and resources to households in need. However, these efforts are challenged by repeated cuts in public health funding, necessitating a shift from reactive responses to sustained action in preventing and mitigating poverty.

At FPH, we are committed to leading the charge against poverty in public health, and have prioritised this as one of our eleven Board Led Focus Areas for action between 2022-2025. Recognizing poverty as a public health issue, we focus on raising awareness, developing resources, supporting professionals, and advocating for policies promoting health equity.

Our Poverty Special Interest Group (SIG), established in October 2022, underscores our commitment to addressing poverty’s root causes and mitigating its impact on health. The SIG has developed a range of evidence-based resources for members to support them to take action in this area, and is developing more. It is collaborating on cross-cutting issues with other SIGs (e.g. on transport, sustainability) to develop webinars for Faculty members.

In 2023 we collaborated with the Royal Society of Medicine, Royal Society of Public Health and the Association of Directors of Public Health to run a one-day event on poverty which led to a consensus statement, a blog, and a summary was reported in an article on the BMJ. We are running a similar event in May 2024.

FPH members in Scotland produced the Scottish Call for Action: The Cost-of-Living Crisis is a Health Crisis: A Call to Action from the Faculty of Public Health in Scotland Oct 23. We have supported the Joseph Rowntree Essentials Guarantee campaign and are exploring opportunities to strengthen collaborative work with ‘Health Equals’ particularly on work and housing.

Recently, the Faculty also led a cross-sector call to support better access to nutritious food for children and families most in need, launching a new report “The Health of the Next Generation: Good Food For Children” at a major event at the House of Lords.

Finally, the FPH is committed to ensuring that the training and examination process for public health registrars addresses the causes of poverty, its consequences for public health and national and local solutions. To achieve this the Poverty SIG is working to identify opportunities to ensure poverty is addressed in the curriculum, in the training resources available and in the assessment process.

Conclusions

Poverty in the UK constitutes a public health crisis, stemming from systemic socio-economic factors. To create a society where everyone can thrive and be healthy, we must address the underlying determinants of poverty, ensuring adequate income, stable jobs, quality housing, education, and access to essential goods and services.

FPH’s work on poverty is centred around advocating for a more just future that fosters a healthier and greener society for all. Together, through collective action and unwavering commitment, we can confront this crisis and build a brighter, healthier future.

Professor Kevin Fenton CBE FFPH
FPH President

Professor Paul Roderick FFPH
Chair, FPH Poverty Special Interest Group

Monday 5^th February marks the start of National HIV testing week, where people across the country are encouraged to get a test for HIV. This year marks the 10^th anniversary of the event, and the last decade (and indeed previous ones) has wrought significant change in HIV care. In view of this change, is it time for us to change the way we think and talk about testing for HIV?

Whilst it is more widely known now that HIV is not a death sentence, and people living with HIV can live long and healthy lives, it can sometimes seem that attitudes around HIV testing have not all moved on to reflect this.

HIV or Human Immunodeficiency Virus was first identified in the early 1980s, but studies of the virus have shown that it had likely been circulating in humans for several decades prior to that, possibly having made the jump from another primate species as far back as the late 1800s.[1] HIV affects the cells of the immune system and leads to low levels of CD4⁺ T Cells (also known as T Helper Cells). Once levels of CD4⁺ cells fall below a critical amount, cell-mediated immunity is lost, leaving the body susceptible to opportunistic infections and cancers. AIDS (Acquired Immune Deficiency Syndrome) is the name given to a number of these potentially life-threatening infections and illnesses that can occur when the immune system is severely compromised by HIV.[2] Many clinicians and people living with HIV (PLHIV) prefer to use the term advanced or late-stage HIV, rather than AIDS.

If diagnosed promptly and started on treatment straight away, most people living with HIV now will never experience late-stage HIV, and treatments mean that people living with HIV live long and healthy lives. [3] Why then, is there still a persistent reluctance to test for HIV amongst many, and sometimes even a reluctance by health care providers to discuss or offer it? Although the covid-19 pandemic makes trends between 2019 and 2022 difficult to interpret, UKHSA data on HIV testing shows that 15% fewer people tested for HIV in 2022 compared with 2019. In addition, amongst those eligible attending specialist sexual health services in England, only 38% of eligible heterosexual and bisexual women tested, with 40% not offered and 22% declined.[4] In contrast, the highest uptake amongst sexual health service attendees was by gay, bisexual and men who have sex with men (GBMSM), of whom 74% tested and only 3% declined. In addition, tests nationally increased by 7% in 2022, making it the highest number ever reported.

This disparity in testing rates is likely multifactorial, but the high uptake in GBMSM almost certainly is related to much of the brilliant work done by organisations working with the GBMSM community and the community themselves. Conversely, and less positively, the lower uptake amongst heterosexual and bisexual women likely reflects something of the persistent myth that HIV only or predominantly affects gay men. In fact, HIV can affect anyone of any age, gender, ethnicity or sexuality, and around half of those living with HIV in the UK identify as straight. In 2022, the UK Health Security Agency (UKHSA) announced that the number of new HIV diagnoses is now higher in people who identify as heterosexual than for gay or bisexual men.[5]

In fact, the problem is more than just a disparity in testing rates. A YouGov online poll in 2021 revealed that around 77% of people in the UK have never had a test for HIV, something which needs to change if we are to achieve the Government’s ambitious goal of ending new cases of HIV by 2030[6]. In addition, UKHSA data released this January have shown that heterosexual testing rates for HIV have still not recovered to pre-covid levels and estimated that of the approximate 95,900 people in England living with HIV, around 4.5% are currently undiagnosed, do not know they have the virus and aren’t on treatment.[7]

A 2010 systematic review looked in detail at barriers to testing as experience by patients and providers in Europe, as well as policy and system barriers. One of the biggest barriers identified at patient/client level in this study was the perception that they were low-risk and therefore did not need a test. This view was prevalent in several population groups studied including test-naïve MSM in the Netherlands, a South London black African community and pregnant women. Other significant reasons cited for not accessing testing were fear of HIV disease, fear of disclosure and difficulty knowing how or where to access a test.[8] Although this study is now over 10 years old, the recent testing figures from UKHSA suggest that some, if not all, of these barriers are still in play to a greater or lesser degree.

The theme for this year’s National HIV testing week is ‘I test’ and aims to empower people to become ‘part of the generation that stops HIV’ by engaging in regular testing. Their website (It Starts With Me) has a wealth of information on HIV, prevention, testing and treatment, and includes information on why it’s important to test. Healthcare professionals may also find this useful to inform their conversations with patients and service users. The key messages are:

1. Testing is the only way to know for sure if you have HIV. Many people may experience a short ‘seroconversion’ illness when first infected with the virus, but this can be mild and is often missed. Consequently, most people with HIV will not have any symptoms at all in the early stages of the illness.
2. If you do have HIV, finding out early is important so that you can commence treatment promptly and stay well. The sooner you start treatment, the less likely you are to experience serious illness and people who are diagnosed early and start treatment can expect to live a normal lifespan.
3. Once you’re on treatment and your viral load becomes undetectable, you can’t pass the virus on to anyone else.

In recognition of the changing picture of HIV as a long-term condition that can be well managed, the CDC has since 2006 recommended routine provider-initiated testing for HIV in all healthcare settings (i.e. at least once in a lifetime for all patients aged 13-64 when presenting to healthcare settings).[9] In reality, this change has been slow in happening, however there is reason for optimism. Not least because of the recent announcement of the expansion of opt-out HIV testing to 46 Accident and Emergency sites across England. It is hoped that the positive effects of this will be two-fold; firstly that this provider-initiated testing will increase diagnosis rates and result in fewer late diagnoses of HIV infection by not missing opportunities to test when patients encounter health services. A second benefit however is that it starts to move HIV testing away from the idea that this is a specialist test, requiring specific counselling skills and only for specific at-risk groups, and more towards the idea that HIV testing should be for everyone who wants or needs it.

In the words of the National HIV Testing Week campaign:

“We have the tools to stop HIV. Each of us can play our part.”

REFERENCES

[1] CDC: Where did HIV come from? Online: About HIV/AIDS | HIV Basics | HIV/AIDS | CDC

[2] NHS Conditions: HIV and AIDS. Online: HIV and AIDS – NHS (www.nhs.uk)

[3] Terrence Higgins Trust: Stages of HIV Infection Online: Stages of HIV infection | Terrence Higgins Trust (tht.org.uk)

[4] UKHSA official statistics: HIV testing, PrEP, New Diagnoses and care outcomes for people accessing HIV services: 2023 report. Online: HIV testing, PrEP, new HIV diagnoses and care outcomes for people accessing HIV services: 2023 report – GOV.UK (www.gov.uk)

[5] Terrence Higgins Trust: Myths about HIV. Myths about HIV | Terrence Higgins Trust (tht.org.uk)

[6] 77% of people in UK have never had an HIV test | Terrence Higgins Trust (tht.org.uk)

[7] THT HIV statistics. Online: HIV statistics | Terrence Higgins Trust (tht.org.uk)

[8] Jessika Deblonde, Petra De Koker, Françoise F. Hamers, Johann Fontaine, Stanley Luchters, Marleen Temmerman, Barriers to HIV testing in Europe: a systematic review, European Journal of Public Health, Volume 20, Issue 4, August 2010, Pages 422–432, https://doi.org/10.1093/eurpub/ckp231

[9] Diepstra KL, Cunningham T, Rhodes AG, Yerkes LE, Buyu CA. Prevalence and Predictors of Provider-Initiated HIV Test Offers Among Heterosexual Persons at Increased Risk for Acquiring HIV Infection — Virginia, 2016. MMWR Morb Mortal Wkly Rep 2018;67:714–717. DOI: http://dx.doi.org/10.15585/mmwr.mm6725a3external icon.

February is UK Lesbian, Gay, Bisexual and Trans History month and in 2024 the theme is medicine, discussing the contributions of LGBT+ people to medicine, highlighting the difficult history of the pathologisation of sexual identity and the health inequalities that still affect LGBT+ communities.

Public Health has an interesting past when it comes to LGBT+ inclusion, in general we have been relatively silent on the inequalities affecting these communities outside of HIV, which I think is to our detriment. The evidence of significant mental health inequalities could be argued to be as strong as that for HIV and STI, yet we rarely see inclusive approaches to public mental health policy and for decades the only recognition of this inequality in policy was a single sentence in the women’s mental health strategy.

It still remains rare for JSNAs to comment on LGBT+ inequalities despite the significant body of evidence of health inequalities. Across the country there have been scattering of LGBT+ specific needs assessments but these are few and far between. This is despite some good work over the years to help pull together the evidence base linked to Public Health outcomes including some key documents from Public Health England:

The Lesbian, Gay, Bisexual & Trans Public Health Outcomes Framework Companion Document (2013)

The Adult Social Care Outcomes Framework Lesbian, Gay, Bisexual and Trans Companion Document (2013)

Promoting the health and wellbeing of gay and bisexual and other men who have sex with men (2016)

Improving the health and wellbeing of lesbian and bisexual women and other women who have sex with women (2018)

These kind of documents are so important in helping us better understand the needs of LGBT+ people. As we improve the inclusion of sexual orientation and gender identity questions into routine and population level data sets we increase our understanding of the inequalities affecting these communities.

Often we tend to homogenise inequalities down to poverty, and it is important to flag that there is international evidence[i] [ii] that demonstrates that poverty is more common in LGBT+ communities than in their cis-gender and heterosexual counterparts, so when we are looking at socio-economic inequality we should be looking at LGBT+ communities as a specific disadvantaged community.

In Birmingham we have built on these further to develop specific community health profiles to help us better understand some of the differences between the L, G, B and T communities as well as their inequalities compared to cis-gender and heterosexual communities. These profiles are desktop needs assessments that are followed by a year of co-embedding with local communities to co-develop sustainable interventions with community members to address the findings. Our JSNA and our deep dive needs assessments include discussion of LGBT+ inequalities, alongside discussion of ethnic and disability disparities, even if it is only to say local data is not available but national or international research shows inequality.

So what does this mean for our approach to training and CPD as public health professionals?

In the Faculty of Public Health’s Public Health Specialty Training Curriculum there is no specific requirement to understand LGBT+ inequalities, the context of diversity and inclusion is limited in the 2022 Curriculum as a cross-cutting theme which only explicitly mentions racism and falls short of the breadth of legally protected characteristics.

This is something the Faculty should consider in future iterations as the curriculum forms the basis of our pre-CCT focus and is key to how we embed the skills and knowledge for the growing diversity of the populations we serve. We have a duty to consider the legally protected characteristics and not create hierarchies of equality in our application of the curriculum and in our training.

However there is plenty of potential in terms of how we demonstrate competency through training and our CPD reflective practice. Specifically if as educational supervisors and ARCP panels we are explicit in our expectation that through training individuals demonstrate cultural competency across the minimum of the nine legally protected characteristics in line with Competency 9.8.

Competency 9.8 ‘Demonstrate cultural competence and is able to work effectively in cross- cultural situations both internally and externally to the organisation.’

Birmingham is currently developing a Cultural Intelligence Framework to support individuals to develop competencies in understanding of different communities. This builds on our work jointly with Lewisham on inequalities affecting African and Caribbean communities and the recognition that public health, and health in general, over homogenised communities and under-valued the differences between them This framework should be launched later this year as an evaluated pilot, but in the interim there is a lot of information, webinars and training available to help deeper understanding of different communities within the LGBT+ and the intersectionality within them.

We have a duty as public health professionals to address health inequalities and it is not acceptable for us to have a hierarchy of equality as this simply increase inequalities in those communities that are ignored. We cannot close the gap unless we go beyond the homogenised over-simplified socio-economic inequality short-hand and to do this we need to get much more granular in understand the diversity of the communities we serve.

So this LGBT+ history month take some time to update your own competency in understanding LGBT Health Inequalities!

REFERENCES

[i] https://williamsinstitute.law.ucla.edu/publications/lgbt-poverty-us/

[ii] https://www.hrc.org/resources/understanding-poverty-in-the-lgbtq-community

With Russia’s invasion of Ukraine in 2022, the Global Violence Prevention (GVP) SIG published an article on this blog laying out the devasting public health impacts on this war[1]. This sparked a discussion between the GVP SIG and the Film SIG about how we could collaborate to raise awareness of the public health impacts of violence through the medium of film.

This idea followed a successful collaboration between the GVP and Film SIGs in 2018, when they created an award-winning animation with Médecins Sans Frontières to mark to centenary of the 1918 pandemic and the end of the WWI[2][3].

To take the idea forward, we approached the Public Health Film Society (PHFS), a UK based charity[4]. The society’s Vice President Dr Olena Seminog is a medical doctor from Ukraine and has been involved in raising funds for medical assistance including the delivery of medical aid packages and first response vehicles. She also has a wide network of contacts within the film industry in Ukraine. She suggested a collaboration that would bring filmmakers from Ukraine together with UK public health practitioners interested in raising awareness about the public health impacts of the war.

The first fruits of this collaboration was a workshop at this year’s UK FPH SRC conference held this September in London. The SIGs and the PHFS invited filmmakers from Ukraine to share their experiences of ‘How to make a film in a warzone’. We were delighted to be joined by award winning director/ writer Alisa Kovalenko and producer Oksana Ivantsiv who showed clips of their films and shared their experiences of filming under dangerous circumstances at the frontline.

Alisa reflected on her experience filming in the east of Ukraine as a young filmmaker during the Euromaidan protests in 2014 and revisiting the sites later to document the lives and dreams of children growing up in the warzone just before the full-scale invasion in 2022.

Meanwhile Oksana described her latest film tracing the mental health toll of the war through the story of a veteran who took his own life and the aftermath for his family including the stigma faced as a result of his story.

The intimate discussions with the filmmakers reiterated the power that films have to put across important messages about the impact of war on children’s growth and mental health through individual stories from the frontline.

We hope that attendees at the workshop were inspired to think about how films could be used to tell important messages about the public health impact of their work. We also intend to build on this collaboration, bringing further insight into the public health impact of the Ukraine-Russian war.

In the meantime, if you are interested in the work of Alisa Kovalenko[5] or Oksana Ivantsiv[6], we have included links to their IMDB profiles in the references and a link to donate to the medical assistance program for Ukraine below.

FUNDRAISING FOR A REFRIGERATED VAN: https://a36.com.ua/en/200-2/

REFERENCES

[1] https://betterhealthforall.org/2023/02/21/public-health-challenges-and-conflict-ukraine/

[2] https://www.fph.org.uk/policy-advocacy/special-interest-groups/special-interest-groups-list/global-violence-prevention-sig/

[3] https://twitter.com/uhoang/status/1140923469372301312

[4] https://publichealthfilms.org/

[5] https://www.imdb.com/name/nm8120909/

[6] https://dzygamdb.com/uk/site/pers-single?id=3119

As I reach the halfway point of my Presidency, I find myself reflecting on both the significant strides we’ve made as a Faculty and the complex challenges that lie ahead in 2024. We face a landscape shaped by domestic and international elections, a persistent cost-of-living crisis, international conflict, and the ongoing threat of communicable diseases like MMR. Our public health teams, already stretched thin, face difficult conversations about prioritisation and the reality of ‘doing less with less’ as demand continues to outstrip our limited resource.

Yet, amid these complexities, the Faculty’s commitment to our members and the vital role of public health remains unwavering. Guided by our Organisational Strategy and Board-Led Focus Areas, we are actively building a stronger, more supportive future for both the profession and the populations our members serve.

For members, your voice matters. This is why our recently launched membership survey is an invaluable opportunity to shape how we support you in the year ahead. Building on the foundations of our 2023 Workforce Wellbeing initiative, we are currently working to establish a network of Regional Wellbeing Champions to co-ordinate work between the Faculty and our members at regional level. Working alongside partners like NHS WTE, we will also deliver our new Workforce Strategy, promoting clarity, equity, and a positive experience throughout your public health journey. We will also continue championing a Fair Training Culture within the profession.

Politically, 2024 presents a crucial window for engagement. With a UK election on the horizon, the Faculty will be a vocal advocate for evidence-based policies that prioritise health and reduce inequalities. This quarter, we will release a major new policy document outlining our recommendations on a broad spectrum of critical public health issues. These recommendations will guide our advocacy in the coming year as we deliver for our members, our profession, and the health of populations across the UK.

Poverty and the cost-of-living crisis remain key areas of focus. Our recent cross-sector report on childhood nutrition, launched in Parliament, stands as a testament to our commitment. Additionally, our work on climate change continues, guided by our Climate and Health Strategy 2021-25. And following the publication of our landmark Anti-Racism Framework, we continue to lead on anti-racism initiatives within our profession and beyond.

We must also recognise the essential role of purposeful, strategic collaboration. Alongside our partner Royal Medical Colleges and other stakeholders, we will work to ensure the NHS prioritises prevention and population health activities. Our Health Services and Health Improvement Committees are currently collaborating on a new report to be published in 2024, further cementing this vital partnership.

Looking to the future, we must prepare for the challenges ahead by harnessing the latest science and technology. Our Distinguished Lecture series continues in 2024, inviting leading public health thinkers to explore these complexities. Our ‘What is Public Health’ campaign will continue to raise awareness about the important and inspiring work that public health professionals do and the impact we have every day. Furthermore, new Special Interest Groups like our Digital and AI SIG demonstrate our commitment to embracing new technologies to advance our work.

Finally, I want to express my sincerest gratitude to all our members who have contributed to our successes in 2023. With such dedication and collaboration, I am confident that 2024 will be a significant year for public health. There has never been a better time to join the Faculty and be part of our journey towards a healthier, fairer future for all.

Together, we can navigate these complex times and deliver positive change. Let’s make 2024 a year where public health takes centre stage, shaping a stronger future for the UK and its communities.

Professor Kevin Fenton CBE FFPH
FPH President

January 22^nd – 28^th 2024 is Cervical Cancer Prevention Week. It is an opportunity to raise awareness of cervical cancer and recognise the symptoms to help women understand how to reduce their risk and prevent illness.

Approximately 14 high-risk types of human papilloma virus account for most cases of cervical cancer. Through regular cervical screening and HPV vaccination, it is a largely preventable disease, and in 2018, the World Health Organization (WHO) called for worldwide action to eliminate cervical cancer (defined as an incidence rate maintained below 4 per 100,000).[1] However, despite it being largely preventable, approximately 3,200 women in the UK, mostly aged 30-34 years old, are diagnosed annually, with more than 800 losing their lives. This equates to nine diagnoses and two deaths a day.[2] Furthermore, data shows that there are ethnic inequalities in the uptake of cervical screening. A YouGov survey (date not provided) commissioned by Jo’s Cervical Cancer Trust found that women from Black, Asian and minority ethnic backgrounds were more likely than White women to report never having attended a screening (12% vs 8%).[3]

The same survey identified barriers to accessing screening for this group of women. These included a lack of awareness about the purpose of the screening test:[3]

• Fewer Asian women aged 20-65 (70%) knew that screening is a test to check cells from the cervix to find pre-cancerous abnormalities than White women of the same age (91%).
• Just over half (53%) of Black, Asian and minority ethnic women aged 55-65 think screening is a necessary health test compared with 67% of White women in the same age group.
• Twice as many Black, Asian and minority ethnic women as White women said better knowledge about the test and its importance would encourage them to attend a screening appointment (30% against 14%).

Women from an ethnic minority background (28%) were also less likely to be comfortable talking to a male GP about cervical screening.[3]

This was reinforced by the findings from another study which found that some women, mostly of Asian ethnicity, would not attend if the option for a female was not there.[4]

Other barriers to cervical screening that have been identified as potentially being more common among women from ethnic minority backgrounds include:[4]

• Considering themselves low risk due to not having a partner or being married.
• Lack of familiarity with the terminology used to describe the test, even among English-speakers.
• Shame and stigma of cancer in some ethnic minority communities.
• Embarrassment among women from older generations.

Addressing ethnic inequalities in screening uptake is an important part of achieving the WHO’s goal of elimination. Targeted education to improve understanding and awareness of cervical cancer and cervical screening among women from ethnic minority backgrounds is likely to play a crucial part in this⁴. Delivery of such education in community settings may be of benefit, particularly for older women, and it should include translating screening invitation leaflets/letters into different languages. Furthermore, it should address the shame, stigma and embarrassment that is experienced by some women from ethic minority backgrounds.[4],[5]

The Faculty of Public Health’s Sexual and Reproductive Health Special Interest Group will continue to seek out opportunities to raise awareness of sexual and reproductive health inequalities, including ethnic inequalities, in line with the Faculty’s anti-racism framework and action plan.

[1] https://www.who.int/initiatives/cervical-cancer-elimination-initiative

[2] https://www.jostrust.org.uk/sites/default/files/jos_cervical_cancer_trust_elimination_report_2023-2_june_1.pdf

[3] https://www.jostrust.org.uk/sites/default/files/bme_survey_website_final.pdf

[4] Barriers to cervical cancer screening among ethnic minority women: a qualitative study | BMJ Sexual & Reproductive Health

[5] https://www.gov.uk/government/publications/health-matters-making-cervical-screening-more-accessible/health-matters-making-cervical-screening-more-accessible–2