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By Gill Rawlinson, Advanced Physiotherapy Practitioner, Salford Royal NHS Foundation Trust 

Earlier this year I was proud to win the Advancing Healthcare FPH and PHE Award for contributions to public health for our innovative service which embedded NHS health checks and diabetes checks within NHS physiotherapy services in Salford.

The project, which was funded by Salford CCG’s innovation fund, allowed us to take a more focussed approach on embedding health promotion principles with the aim of supporting our patients with musculoskeletal problems to make positive lifestyle changes.

Salford Royal NHS Foundation Trust provides physiotherapy services to some of the most deprived parts of England where health inequalities are large and health and lifestyle factors contribute greatly to ill health and premature mortality. From the initial project aims of creating a culture where patient’s health and lifestyle was central to their care, and where physiotherapists were encouraged to support behaviour change with individuals, the project quickly grew and partnerships developed with both public health at Salford City Council and the Salford National Diabetes Prevention Project (NDPP).

This allowed us to share our common goals and work collaboratively to deliver NHS health checks and diabetes check within routine physiotherapy appointments, the first service of its kind in England. This approach not only puts public health principles and prevention at the core of clinical assessment, but allows the opportunistic delivery of supportive interventions, such as motivational interviewing, at a time when patients are seeking help with a health problem and are often keen to make positive behaviour changes.

Helen Slee, Project Manager for the Salford NDPP, supported me to collect data which facilitated the identification of eligible patients and to collate a health profile of our patients. This data allows us to record our public health interventions and to evaluate our impact as a public health workforce. The project supports the Five Year Forward View NHS England strategy which challenges us all to put prevention at the heart of what we do and also illustrates the use of physiotherapists and wider Allied Health Professionals as an untapped public health workforce. Since the pilot project we have been supported by our Public Health team and Salford CCG to develop and scale up the project. We plan to evaluate the data further and publish the findings in the coming months.

Winning this award has allowed me opportunities to share and disseminate our project with many other organisations across the country.

It has also allowed me to meet many other people with a passion for public health who want to change things for the better, including leaders in AHP services and quality improvement. Most importantly it gave welcome appreciation and recognition to our many staff who embraced change and challenges to deliver an improved service, supporting our patients to live longer and healthier lives.
Why not think about entering for the award this year to share your great public health practice and celebrate your team’s successes? You never know where it may lead!

By Dr Lesley Graham, Associate Specialist, Public Health for Alcohol, Drugs and Health in Justice, ISD, National Services Scotland, and Faculty of Public Health Representative, SHAAP. Dr Harpreet S Kohli, Retired DPH, Co-opted Member, SHAAP.

The UK Supreme Court has  unanimously ruled that the Scottish Government’s legislation on Minimum Unit Pricing is legal. This is a landmark moment for public health and the end of a long journey. However, it also marks the start of a new journey to implement MUP to reduce alcohol-related harm in Scotland. When implemented this will mean that no alcohol can be sold in Scotland for less than 50p per unit.

Although the Alcohol (Minimum Pricing) (Scotland) Act 2012 was passed 5 years ago by the Scottish Parliament without opposition, global alcohol producers headed by the Scottish Whisky Association took the Scottish Government to court. There followed a lengthy and costly battle (in terms of lives lost, time, and money) all the way to the European Court of Justice and back to the highest court in the UK. This victory has been a huge collaborative effort from many players with public health at the heart of it.

Just over 10 years ago, an alcohol advocacy group, Scottish Health Action on Alcohol Problems (SHAAP) was set up and we were the Faculty of Public Health representatives. SHAAP was established due to concerns about the epidemic levels of alcohol harm in Scotland being driven by increasingly cheap alcohol.

Our report, Price Policy and Public Health was the first public call for action to introduce a minimum price for alcohol. The incoming SNP Scottish Government took up that call. As well as targeting the Scottish Parliament, SHAAP reached out to build alliances at global levels. By 2010, WHO (World Health Organisation) were recommending MUP as a policy ‘Best Buy’.

The broad scope of the role of public health has allowed us to contribute in a variety of ways, including:

  • Production of routine national statistics
  • Policy development
  • Advocacy
  • Research
  • Evaluation of the implementation of MUP in terms of what alcohol-related harm means for health boards in Scotland such as service provision

Here are some of our reflections of that journey

First, the importance of a sound evidence base. Although MUP had never been tried and tested before, we had based the rationale on the evidence of the relationship between price, consumption and harm. The more price falls, consumption rises and so does harm. That sound evidence base proved its worth in the sometimes stormy debate that was to follow.

Second, we had ‘reframed’ the problem with a public health paradigm, if average population consumption would fall, so would harm. This helped move the narrative away from being the problem of a minority of individuals or one of anti-social behaviour.

Thirdly, those from the most disadvantaged backgrounds experienced greater levels of alcohol related harm, indeed, those inequalities were widening. It was a matter of social justice. We had champions, both political and public health who went out and campaigned hard and did not give up.  Other countries now are poised to follow Scotland’s lead.

Lastly, we think it is more than about alcohol policy. It shows that public health can trump private profit and the alcohol industry. A great moment indeed!

 

The Chief Nursing Directorate at Public Health England (PHE) and the Florence Nightingale Foundation (FNF) are offering a bespoke scholarship a bespoke scholarship named after an inspirational public health nurse who sadly died in 2016.

The award is in memory of Nana Quawson, a dedicated school nurse and practice nurse who sadly passed away last year. Nana was passionate about improving the health and wellbeing of children and young people through evidence based public health interventions. She spent time with the Nursing Directorate in the Department of Health and Public Health England sharing her expertise, ideas and enhancing her public health leadership skills.

The FNF scholarship builds on Nana’s journey and aims to provide a fabulous opportunity for a public health nurse to enhance their leadership and become a strong leader with the skills and self-confidence to contribute positively and make a tangible difference to the outcomes for children, young people and families. As part of the scholarship we are delighted to also offer a work based placement within the Chief Nurse Directorate at PHE and work with the team on raising the profile of public health nursing, prevention and improving the health and wellbeing of children, young people and families.

This scholarship remembers the dedication, passion and drive of Nana Quawson (1972-2016), a valued colleague and school nurse. The scholarship provides the opportunity for other public health nurses to follow in Nana’s footsteps and make a difference to children, young people and families.

For further information please visit the FNF website. To find out more about our work at PHE please contact Wendy Nicholson or Penny Greenwood.

 

By Dr Samia Latif, member of the Global Violence Prevention special interest group at the Faculty of Public Health

Pakistan, Afghanistan, Syria and Nigeria have something common between them other than being third world nations. They are the only remaining countries where polio, amongst other infectious but preventable diseases, still ravages and raids childhood and the dreams of an entire generation.

Vaccinations have been one of the single most effective public health interventions known to mankind but in order for a good immunisation programme to take root there needs to be a safe and stable environment to deliver the vaccinations alongside a good understanding of the political context in which these immunisation programmes operate. These countries have been in a state of conflict recently and as such, Polio triumphs along with other childhood infectious diseases.

Wars, insurgencies and conflict drive resources away from the basics such as health, education and societal structures. Ways of life are disrupted which is further compounded by forced migration, displaced populations and a breakdown of trust. It comes as no surprise then that polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns.

There is evidence that hostility to immunisation programmes may not necessarily be the result of insurgents’ theology, rather it arises from suspicion and mistrust. For example, in Nigeria, the last African country harbouring endemic polio, many believed that the vaccine contained anti-fertility drugs and cancer-causing viruses. Similar misconceptions were rife in Pakistan where the Taliban insurgents propagated rumours that led to the targeting and killing of healthcare workers delivering the vaccinations; such can be the indirect and uncalculated costs and victims of conflict! It did not help of course that America had used the immunisation programme as a cover up for its spying operations.

Trust is key to the acceptance and success of any public health intervention but more so for an immunisation programme that involves inoculating apparently healthy individuals with weakened strains of microbes or antibodies to the same.

Access to healthcare is a major determinant of health; war and conflict destroy the routes and health and social care structures to access so it is no wonder then that war and infectious diseases are such good comrades. Add to the picture of already exhausted and fragmented health and social care the genetic evolution of bacteria and viruses causing infectious diseases and you have a recipe for disaster that cooks for many years even after the conflict or war has ended. Lack of access to immunisation programmes, antimicrobial resistance and changing strains of microbes may have very long lasting effects that are witnessed by subsequent generations as herd immunity falls below optimal levels. Bosnia and Herzegovina being a case study in time where the recent measles outbreak was a consequence of the conflict 20 years ago.

In today’s global context, when borders are increasingly porous and diseases neither respect nor recognise these borders, the challenge posed by global conflict threatens the very premises on which our society’s foundations of health and social care have been laid. A clear example is the resurgence of polio in Iraq 14 years after being disease free due to spread from neighboring Syria.

A problem thousands of miles away does not mean it won’t come knocking on our doors soon. There needs to be a united call to arms by world leaders and all levels of society to advocate for peace, building trust and working with and through communities; something public health does best!

By John Middleton, FPH President

better mental health infographic

Mental health in the workplace is the theme for this year’s World Mental Health Day today. The workplace is a key setting for health as good work is a key determinant of health.

Job control, fair treatment, job security and reward for our efforts are what characterise good work. Those who lack autonomy to do their job, have insecure terms and conditions, are treated unfairly or receive no praise or recognition from their managers will feel their health suffer. This in turn will impact on productivity, staff retention and sickness absence.

Sadly, we too often see workplace mental health action focussed on individual behaviours rather than organisational actions that tackle these determinants of health at work. Workplace wellbeing has become extremely popular but yoga at lunchtimes may do little, if anything, to tackle the causes of stress.

The National Institute for Health and Care Excellence (NICE) guidance for workplace health recognises the organisational commitment needed, the role of good line management and the value of staff participation in decision-making. It also recommends the Health & Safety Executive’s excellent management standards for workplace stress. The public health workplace is not exempt. There are many stressors out of our control but there is also much that we can do. As well as implementing the NICE guidance or management standards we can also look out for one another. Relationships are key for good health and equally so at work.

Being aware of our own mental health and wellbeing is the start of taking any action. This helps us improve our communication with others and create meaningful solutions with others. The revised Faculty of Public Health (FPH) curricula 2015 included a new learning outcome that we could all do more to demonstrate and apply: an understanding of how mental health and wellbeing can be managed and promoted in staff and yourself in a range of situations.

Mental health remains a priority for FPH and for me personally. Last month I pledged FPH’s support by signing the Prevention Concordat for Better Mental Health that we have contributed to through our Public Mental Health Special Interest Group. We will continue to take action, to support our members in their practice and to advocate nationally for the public’s mental health.

As a standard-setter and educator, we will include positive mental health in our education and training programmes, and we will work to become a Mindful Employer.

By Dr Tina Maddison, CCDC PHE West Midlands Team

Human trafficking is the acquisition of people by improper means such as force, fraud or deception, with the aim of exploiting them (1). Sexual exploitation is by far the most commonly identified form of human trafficking (2), with women and girls disproportionately affected (3). This is a problem that is not diminishing.

Indian brothel

Inside an Indian brothel

My husband and I are currently volunteering in South East Asia for an NGO that rescues and rehabilitates children from human trafficking and sexual exploitation. My husband has recently returned from India where he witnessed first-hand the prolific nature of this trade. Many of the women and children are subjected to sexual exploitation either by the families into which they are sold or in the public brothels that line the backstreets of countless cities.

 

In New Delhi, home to a myriad of brothels and massage parlours, children as young as 12 are sold to men up to 40 times a day. This abuse is beyond comprehension. The damage to the individual, both physically and emotionally, is catastrophic. Babies born to these girls are also used for the gratification of perverted minds.

Abha was just 12 when she was trafficked into a brothel in Delhi (4). “I was kept day and night in that place. They made me go with men all day and all through the night. If I resisted the owners would cut my arms, burn my face with cigarettes and scald my body. They would open up my wounds the next day to remind me not to disobey. They would inject me with drugs and force me to drink alcohol to make sure I did what I was told.
Whilst I was there I caught TB from the other girls. Seven men escorted me to hospital; they did not let me out of their sight. I was a prisoner, and I lost all hope of ever escaping. Eventually I tried to kill myself by cutting my wrists. They stitched me up so I could carry on making money for them.”

Across South East Asia, in the poorest of towns and villages, families are forced to make agonising decisions just to survive. Fathers will sell their oldest daughters to feed their younger siblings. The fundamental human rights of a child have no meaning in a world of extreme poverty.

Cultural issues in some countries contribute to the problem. Women and girls are viewed, by many, to be of little significance or worth. This diminished social standing is exploited by organised criminal gangs who view young girls as objects to be bought, auctioned and sold. To them women have a high value but for all the wrong reasons.
The crisis in India, where woman and girls routinely face sexual exploitation, harassment and lack of human worth has, in recent years, been amplified by the availability of pornography on the internet. One exasperated Indian social worker put it like this: “Pornography has intensified the lack of respect for women here. The problem has become much worse in a short space of time.”

Where does our public health duty lie in response to the appalling reality faced daily by girls such as Abha? Poverty, disregard of a woman’s worth and the prevalence of pornography are all underlying factors in this human tragedy. Should our response be to attempt to deal with these fundamental problems?

If these root causes are just too enormous a challenge, then should our public health response be to deal with the aftercare of individuals directly affected? Children rescued from the brothels have been broken mentally, physically and spiritually. Many suffer with rejection, they cannot reconcile the fact that their own families could have sold them. For others, the shame they burden for the abuse they have suffered is a barrier to ever being reunited with loved ones. They become outcasts.

Those still trapped within this insidious industry suffer with even greater self-degrading effects. A sense of hopelessness inevitably leads to depression. Many try to take their own lives as their only means of escape. Others develop a dependency upon the drugs and alcohol they are plied with in an attempt to block out the fear and pain they have been sentenced to.

Our public health response could be to identify and develop services to deal with these devastating emotional effects on young lives. Or as public health practitioners we could respond to their physical needs; screening and treating TB, HIV and other STIs, improving their poor nutrition and working to ameliorate their squalid living environments.

However, within India and neighbouring countries, for many there is still an unwillingness to admit that such problems exist. On the flight into Delhi one Indian passenger was adamant there were no issues with prostitution in India. “You will not be able to show me even one woman or child in prostitution. There is no problem here, this does not happen!”

Perhaps, therefore, our public health duty first and foremost should be to continue to raise awareness about this atrocity so that no one can honestly deny that the problem exists. Unless the issue and scale of human trafficking is recognised and acknowledged by all countries, and political pressure applied at the highest levels to invoke change, then those on the ground who fight daily against such evils will continue to fight alone.

“The only thing necessary for the triumph of evil is for good men to do nothing” – Edmund Burke

References:

1. UNODC. UNODC on human trafficking and migrant smuggling. Available at URL: http://www.unodc.org/unodc/human-trafficking/ (Accessed 8 May 2017)

2. UNODC. Global Report on Trafficking in Persons. Executive Summary. February 2009.

3. International Labour Organization. Summary of the ILO 2012 Global Estimate of Forced Labour. June 2012

4. Abha – not her real name. Notes from a personal conversation with a girl rescued from a brothel in Delhi, May 2017.

By Prof John Middleton, FPH President

John Middleton 2 web

August was a stock-take month for me. I held several meetings which all pointed to the need for public health and the woeful neglect of public health expertise by local, national and international policy makers.

Early in August we held a productive session of the Global Violence Prevention Special Interest Group which resolved to look at training tools for work in conflict and post-conflict areas – how to make rapid needs assessments, how we build alliances with public health resources in conflict areas and how we make sense of prevention and resolution of conflict through working with political scientists, theologians, international lawyers and aid non-governmental organisations. The work is being led by Daniel Flecknoe and Bayad Nozad. We plan to join up this work with that of Brian McCloskey and David Heymann for Chatham House (Royal Institute of International Affairs) looking at emergency responses in conflict zones. Mark Bellis’s work for the Commonwealth will also play a key part. The FPH statement says our unique role is in preventing violence and building and implementing the evidence base – locally, nationally and internationally. Economic inequality and unequal power-sharing are major causes of violence at local, regional and international level, and major challenges for the public health community, whether in relation to violence, childhood obesity or premature mortality. It is clear to me that FPH can play a greater role in violence prevention by harnessing the disparate skills of our members, from the frontline to high-level international policy – in emergency preparedness, health protection and health services organisation and in public mental health and community development.

In August I also met with David Ross from the armed forces public health services. They clearly have much expertise to contribute – in relation to international conflicts and closer to home. We have resolved to have a meeting with forces colleagues in the new year. The root causes of violent behaviour are also often the root causes of accidental violent injury. This was never more demonstrated than with the Grenfell Tower disaster. I am pleased that we could respond to the terms of reference consultation for the inquiry. Sadly our representations were not heeded and a limited range has been set for the inquiry with a junior minister leading consultation on the implications for social housing and some superficial examination of the causes of the causes. Nevertheless, I am extremely grateful to the FPH members who responded rapidly to our request for help on the Grenfell submission and particularly to Ruth Gelletlie who put together our response on the terms of reference. We received a wealth of material on every aspect from health protection and response, public mental health responses, health inequalities and the London housing market, building design, regulation and controls and social issues regarding migration and homelessness. Ruth and colleagues in the revitalised Housing and Health Special Interest Group will be drawing on this material for our formal submission to the inquiry (and for a listening minister…?)

A sustainability and transformation partnership has announced a £2.7million contract with the private sector for a year’s support for an accountable care organisation. It’s a mind-numbing figure and would buy an awful lot of public health health-care expertise and analysis. We will follow this programme carefully and see what it teaches… and in the meantime, continue our work to rebuild training and capacity in healthcare public health.

As we return from the summer holidays, FPH will once again get into full swing with major policy-planning days. Our workforce strategy is nearing completion and will be formally signed off in November. We are much exercised by the need to build our membership and would urge you to invite all your colleagues to join us – we have a category for virtually everyone working in public health or associated with our work. I will also be involved in the Academy of Medical Royal Colleges planning days. Our policy team priorities on Brexit and public health funding are taking shape. I will be at the Public Health England conference in Warwick at which we will launch the Public Health Prevention Concordat for good mental health. I will also be speaking at MEDACT’s conference in York with the International Physicians for the Prevention of Nuclear War on the theme of the progressive-health movement. I will also be speaking at the Oxford public health registrars symposium on the theme of partnership in public health. I believe there are still places available at all of these meetings.

As the US President flexes his nuclear options, and our government stumbles over complex imponderables of Brexit, it is clear to me we absolutely need a progressive health movement which addresses inequalities in income, in opportunity, in education and environment, which understands and builds new programmes for public mental health and conflict resolution, which stands strongly for non-violent resolution of problems, which looks at the health impacts of all policies and across future generations, and which believes in partnership, in shared benefits and better outcomes for all.

Can I draw your attention to an exciting event coming up which provides a unique opportunity to share learnings about advocacy. Mike Daube, Professor of Health Policy at Curtin University, Perth, Australia, will be delivering the DARE Lecture entitled ‘Not a Spectator Sport: public health advocacy and the commercial determinants of health’ on 27 September in London.