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Time is running out.

There is a climate emergency and we have only a few years left to keep global warming at safer levels, beyond which we may cross tipping points and activate feedback loops it is near impossible to reverse.

2019 may well be the year the world’s collective consciousness was finally awoken to the reality of the climate and ecological emergency and the pressing need to act decisively. Many social movements have begun to appear and raise their voices to protest at the lack of political leadership on this, the defining issue of our time. This includes an increasing number of health professionals, who are clear that the climate emergency is a health emergency and are demanding decisive action from organisations and political leaders. Impacts of climate change, including extreme weather events, the spread of infectious diseases, and food and water insecurity, will affect the vulnerable the most.

Whilst the UK government has declared a climate emergency, the underpinning policy ambition to respond to this remains unclear and ill-defined. The UK is not on target to meet its international obligations under the Paris Agreement. There is a strong social justice argument that due to high historic emissions, the UK should go faster and further on its commitment to achieve net zero.

The next few years may be the last in which we, and our political representatives, still have the opportunity take decisive and timely action on the climate emergency.

We are a group of UK health professionals who have come together to highlight the link between health and climate. We have worked to scrutinise manifestos of the main political parties in England, Scotland, and Wales and score them on their commitments relating to climate and health. With reference to the Lancet Countdown and UK Health Alliance on Climate Change policy recommendations, we developed a list of policy areas, which was refined through discussion and a shortlist agreed. Each manifesto was scored independently on our final five criteria of clean air, low carbon economy, transport, food and farming, and green homes. We have produced an infographic demonstrating how party manifesto commitments fare on plans to tackle the climate and health emergency.

CLIMATECHANGE

Good health for our families, our patients, our communities, and our population depend on a stable climate and healthy ecosystems. The next Government’s policies must reflect these pressing concerns and we must hold them to account for any promises made in their manifestos.

Blog written by Dr Sarah Gentry and Dr Ruth Speare in conjuction with Dr Yas Barzin, Dr Isobel Braithwaite, Dr Anya Göpfert, Dr Chris Newman, Alexander Crane, Michael Baldwin, Dr Oytun Babacan (Imperial College London) and Dr Iain Staffell (Imperial College London)

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Jacquie White, NHS England Director, explains why Public Health teams are needed at the top table of Integrated Care System discussions on Population Health

“The physicians surely are the natural advocates of the poor and the social problem largely falls within their scope.”

Reading this lovely quote from Rudolf Virchow on the front of the Faculty of Public Health’s Curriculum for Medical Schools made me think how many more opportunities we now have to tackle the fundamental issues impacting on our health and wellbeing by working together in Integrated Care Systems.

While local health and care teams are faced with the reality and consequences of ill-health daily, the partnerships in local systems are enabling and encouraging collective responsibility and action to start to solve some of the underlying determinants driving this.

And I believe we’re starting to see fresh shoots.

The NHS England and Improvement Population Health Management programme is trying to move our shared efforts in that direction and we really need your help.

The aim of the programme is to support local health and care systems and their emerging Primary Care Networks to work in partnership to improve care, and consequently to improve people’s lives, by designing local solutions to address the needs of local people.

I’m inspired daily by the enthusiasm and wealth of skills in public health teams who are driving a focus on proactive, preventative approaches to improve outcomes and reduce inequalities.

To help people struggling with health problems stemming from societal issues such as employment, environmental issues like air pollution, and behaviours like smoking, we need to learn from what’s already been achieved in public health.

With this in mind, the new Population Health Advisory Board, which includes your faculty’s President Maggie Rae and other public health expertise, will be key to guiding the programme and its ambitions over the coming months and years.

So much work has already been done, and the advent of Integrated Care Systems means we can now go further faster bringing together more skills in these partnerships and expanding our collective capacity.

With the NHS, councils, VCSE and other public services all around the table looking at new and very rich linked datasets and predictive analyses we’ve got a huge opportunity to tackle common problems together to maximise the impact and reduce duplication of already stretched resources. It allows systems to have a shared understanding of who their population are, and what is best for them in the long term.

For anyone not familiar with the NHS England and Improvement PHM programme, it’s the NHS’ commitment to working with local authorities and particularly public health colleagues to understand current, and predict future, health and care needs.  

It aims to help local systems and their providers design and deliver anticipatory and personalised care and support for individuals, more joined up and sustainable health and care services for local populations and make better use overall of public resources.

It’s the first time we’ve been able to bring together and analyse the right data to generate  local discussions in systems by the right groups of people about improving the health and well-being of communities. This includes health professionals, managers, commissioners, providers, data analysts, business intelligence, social care and of course public health colleagues.

So far, wave 1 of the programme has made some fantastic and very speedy achievements locally with more than 1,000 people being better supported, teams designing and starting to deliver new models of care for populations and inspiring the local workforce to feel re-energised about their jobs.

In Lancashire and South Cumbria for example, they focused on the wider determinants of people’s health using their links with the community and borough councils.

Primary Care Networks (PCNs) with their wider multi-disciplinary teams initially segmented their population and then asked analysts to bring in further insight – for example on assisted wheelie bin collections or where people are living in houses of multiple occupation – to help narrow down a specific at risk and impactable cohort of patients for initial action.

From the data – and following further predictive modelling on costed population segments –  they found people with needs not met by existing models of care, who are likely to experience a greater deterioration in health than others within similar population groups and who are likely to account for significant utilisation of health and care services in the next few years. They then worked together with local communities to design and agree a proactive tailored care model, including support for health, psychological and social needs.

The Public Health teams at LSC have been leading this work and were a fundamental part of its delivery.

Given that the potential for opportunity is greatest in influencing the wider determinants – and that we know only a small fraction of the factors that impact our health come down to our access to health services – we need more leaders from public health to help us in this mission. To succeed we must connect this work in systems with local teams and communities, and the leadership and expertise from Public Health is invaluable.

If your area is taking part in our programme or beginning to join up action on PHM then please get involved – we want this to be the kind of social movement Rudolf Virchow would be proud of.

Join the PHM Academy for lots more information and news on the development of PHM around the country.

“Refugees are mothers, fathers, sisters, brothers, children, with the same hopes and ambitions as us – except a twist of fate has bound their lives to a global refugee crisis on an unprecedented scale.” Khaled Hosseini

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According to data from UNHCR, displacement has risen to the highest level ever recorded, with an unprecedented 70.8 million people being forced from their homes and 25.9 million living as refugees.1 A growing number of people are living long-term in settlements; raising families, seeking jobs and attending school. Furthermore, NCDs such as cancer, diabetes and heart disease are rising, contributing to 80% of deaths in LMICs.2 This sheds light on the need to develop effective approaches to respond to, and treat the needs of, these populations. Recognising this need, an exploratory study was developed in collaboration with the International Rescue Committee (IRC) to investigate effective interventions for NCD prevention in LMICs, exploring opportunities for such interventions in a refugee setting. This May I spent time in a refugee settlement in northern Uganda conducting research for this study and I want to highlight three personal takeaways from my experience in the camp.

Getting off the small propeller plane in Arua with my colleague to await our vehicle, I wasn’t quite sure what to expect. While I had spent time in Africa before, this would be my first time in a refugee camp. Walking through the Ebola check point I stood still as the worker took my temperature. Next, our bags were loaded, and I hopped in the car as we set off on the hour journey to BidiBidi, one of the largest refugee camps in the world.

It was hard to tell where the town ended and where BidiBidi actually began. But as we neared the centre aid worker flags clearly defined the space. Every person we encountered, from the driver and NGO workers, to the refugees, were kind and welcoming. Eager to start our work, my colleague and I quickly started making plans. However, I was soon to learn the first of my three key lessons!

  1. You will need to be adaptable

While having a plan is nice, you need to have a plan B, C and D and be prepared to think on your feet. Much of the nature of working in international development is dealing with setbacks and this was just as true with my research. In a refugee camp food rations are distributed on certain days, therefore if someone you are meant to interview is due to pick up food, that will be their priority. Additionally, locations will be moved due to other meetings taking place and time works a bit differently. When we wanted to hold our first focus group at 11:00am the health officer would happily tell the participants to meet at 9:00am. However, with a good attitude and entertaining colleagues, the underlying chaos ended up being my favourite part of the experience, as this was a true reflection of the reality.

  1. Context is key

Much of my research was around addressing risk factors such as tobacco and alcohol use, unhealthy diets and lack of physical activity. Therefore, it was critical to understand the population; what are the drivers behind behaviours, what is the availability and accessibility and are there mechanisms in place for regulation? In BidiBidi the majority of the population are South Sudanese refugees who are Muslim; mostly women and children with little education. Shadowing a community health worker as he went into the villages gave me insight on the daily lives of the refugees and how to adapt research findings for this particular context.

  1. Community is everything

Lastly, and most importantly, community is everything. Many of the people I spoke with escaped from war-torn South Sudan, witnessed violence and experienced discrimination. But the way the community remains cohesive, supports each other and stays positive, despite all circumstances, is inspiring. The doctors, health officers and community health workers are a united team working to break barriers and tackle challenges. Hopefully as new research and new technology emerges, it can be introduced in settings like BidiBidi. An advantage of working with the IRC is that they are an implementing organisation; research is put to practice and the people they are serving have a voice. While the current statistics are daunting, the people have the will and the capacity to introduce effective interventions which can prevent NCDs among the refugee community, creating better health for all.

 

Blog written by Lara Kontos, MSc Global Health

 

References

  1. UNHCR (2019) Figures at a Glance. Available at: https://www.unhcr.org/uk/figures-at-a-glance.html (Accessed 14 August 2019).
  2. World Health Organization (2018) Noncommunicable diseases. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (Accessed: 18 July 2019).

Hertfordshire has led the way in improving levels of physical activity in older adults via a social marketing campaign ‘Never Too Late’ which has seen almost 4000 people sign up – 4 times our target.

Never too late photo

The 12-week campaign with a budget of £20,000 launched in April 2018 across social media, local Daily Mile schools (with children inviting older adults to join them for their Daily Mile), and through a wide range of partner organisations.

The campaign formed part of Hertfordshire’s Year of Physical Activity. It reached three quarters of a million people and generated nearly 30,000 hits to our webpage. The evaluation found that of those who reported doing no physical activity at the start of the campaign, 93% reported doing at least 30 minutes of physical activity per week at the end of the campaign. Overall, 79% of participants reported moving from doing less than 90 minutes of physical activity to doing more than 90 minutes per week by the end of the campaign. Just over half of those completing our post-campaign survey have reported meeting or exceeding their physical activity goals.

It targeted over-55s but messaging was tailored for specific behaviours, informed by insight from local focus groups and Sport England research. Key barriers (anxiety, lacking role models, thinking they do enough exercise already) and motivations (keeping up with grandchildren, healthy mind/body, social belonging, confidence, getting more from life) were central to messaging, which also promoted easy ways to fit ten minute activities into everyday life.

In Hertfordshire 42% of 65+ year olds are inactive and 58% do not meet national recommendations for physical activity. We used evidence-based behavioural science techniques (based on the COM-B Model) to encourage behaviour change:

  • Action-planning/progressive tasks: an activity planner enabled people to move from intention to action
  • Behavioural practice: personalised support from trained staff offered in a way that best suited participants’ needs
  • Prompts: twice-weekly text/email messages, targeted by key motivation (health, social, mobility, enjoyment)
  • Incentivisation: free activity pass and entry into prize draw for all participants
  • Nudge theory: sign-up to resident e-newsletter provided ongoing contact beyond campaign

We used a range of tactics and channels to target residents:

  • All traffic driven to webpage, which hosted case studies, information and registration survey. Through this we captured baseline and follow-up data to evaluate success.
  • Creation and sharing of a suite of insight-led online content tailored to different groups, in particular tapping into the over-55s growing love for Facebook. We reviewed and updated regularly to keep fresh and promote best-performing content.
  • Blitzing local and regional media, developing stories and media packages across the county.
  • Developing unique and impactful relationships with partners to maximise reach and success.
  • Identifying key periods of activity (our successful media launch and the 40+ school launch events) and supplementing these with ongoing activity across our own and partners’ communications channels. We cascaded messages, using key hooks and milestones to celebrate success and sharing pictures/videos from events.

Hertfordshire County Council’s director of Public Health, Prof. Jim McManus, said: “This campaign has demonstrated effective use of behaviour science techniques to help older people get closer to the guideline of 150 minutes of physical activity per week. This is an important element of our prevention agenda”.

“As a result of this success, we’ll be running the campaign again from 5th May 2020 in the lead up to the Tokyo Olympics”.

Case study

One person who found the campaign of benefit was Jim Furman who is 69 years old and retired. “I am much more positive than I was, both mentally and physically. I always feel better after any kind of physical activity, especially when it is enjoyable, which the activities I’ve discovered through this campaign are”. He heard about the campaign through the Council’s email newsletter and was very interested in the free day trial offer. “It has made a big difference to activity levels for both my wife and I. She has signed up to be a regular member of Stevenage leisure centre as a result of the free trial and we both now play badminton there together every week. I was very impressed with the gym. I was amazed at the whole set up, the equipment and facilities – I hadn’t realised how good they were. There was one particular activity I really enjoyed – a walking machine with a TV screen – and I’d love to go back to try that again, it was fun and made me feel really positive about exercising”.

 

Written by Nicola Ainsworth, Specialty Registrar (ST3), Hertfordshire County Council

“The earth is sick. It has a temperature. We know the diagnosis. It needs treatment. If it is not treated it will become sicker – its temperature will go on increasing until it dies. We may have reached a tipping point. Urgent action is needed.”

Following the global launch of the Manifesto to Secure a Healthy Planet for All, Prof. Jo Nurse gave this warning at a recent event in Wessex to support local councils in taking emergency action on climate change.

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With so many local authorities declaring a climate emergency, Prof Nurse collaborated with the University of Winchester and the Wessex Global Health Network to provide an afternoon of speakers and workshops designed to assist councils in taking climate action.

Prof Joy Carter, Vice-Chancellor, was well placed to give the opening address given that Winchester is the University for Sustainability and Social Justice and has itself declared a climate emergency. Dame Yvonne Moores, former Chief Nursing Officer, chaired the event which had over 60 attendees ranging from Public Health consultants to emergency planning officers, local Councillors and NHS representatives.

The scale of the challenge facing local government was illustrated by speakers from Hampshire County Council, Winchester District and from the new unitary authority of Bournemouth, Christchurch and Poole. These were followed by presentations giving practical advice on the steps that authorities can take including 50 actions from Friends of the Earth and Ashden’s co-benefits toolkit.

The afternoon included workshops designed to highlight the key issues and then bring the discussion onto actions to prevent and mitigate climate change.

As a Public Health Registrar, currently working in global health, I found it inspiring to see the enthusiasm and commitment of my local authority colleagues despite the many challenges and barriers to tackling climate change. The scale of the emergency is daunting, and it is easy to feel overwhelmed and helpless. Nevertheless, local areas are coming up with innovative solutions and there is a strong will to engage with the public, particularly with influential grassroots organisations and with young people.

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In the workshop that I attended, there was a focus on the role of behaviour change; local authorities were asking for support from national experts in the social marketing of climate change actions. I was struck that the Public Health community has a strong track record in framing messages in a way that promotes behaviour change and, therefore, this is one area where our profession can really support council colleagues.

Going forward in Wessex, it is hoped that stronger networks will facilitate cross-sector action by allowing the skills and expertise of many different disciplines to come together; Public Health professionals with their competencies in engagement, influencing and behaviour change should be key players in the response to the climate emergency.

Written by Rebecca Wilkinson, Public Health Registrar on placement with the Wessex Global Health Network

Unlike most visits to Ghana, this trip was particularly special and a “mission” rather than a reunion with friends and family. My yearning to make this a success had me constantly refreshing myself on the terms of reference and action plans for the trip, which, I guess, was the culmination of a partnership ‘journey’ that started in the latter part of 2018 involving various emails, teleconferences, text messages and phone calls!

My first day (and first time) at LEKMA hospital, started with some personal observations (and to have a moment to myself).  Afterwards, on the way to see the Medical Superintendent, Dr. Ameh, I saw one of the pharmacists that I recognised from one video conference call. I called him by his ‘English’ rather than Ghanaian name, thereby giving away who I was, but more reassuring was when he mentioned they were expecting me (as did Dr. Ameh when we met).  This bode well for the visiting team.  With initial introductions over, I went into planning times for the Global Point Prevalence Survey (GPPS) which took place over subsequent days with two Pharmacist colleagues.

Samantha arrived a few days later. The rest of the team arrived after Samantha, but the excitement made me go to the airport. Waiting like it was Christmas!  The next morning, we all met for the first time and were driven to LEKMA Hospital.

Our first day LEKMA was extremely pleasant with the usual warm Ghanaian hospitality.  The enthusiasm was apparent from the get-go.  We ran through the agenda for that day and duration of the visit followed by ward/departmental visits.

 

pic1FPH Africa SIG Ghana Visiting Team (left to right)

  • Mr Edwin Panford-Quainoo, Public Health Pharmacist, Liverpool School of Tropical Medicine
  • Dr Rajesh Rajendran, Consultant Microbiologist, East Cheshire NHS Trust
  • Dr Valérie Decraene, Consultant Epidemiologist, PHE Field Service
  • Dr Sam Ghebrehewet, Head of Health Protection, Public Health England, North West (FPH Ghana Visiting Team and Partnership Project Lead)
  • Dr Saran Shantikumar, Clinical Lecturer in Public Health, University of Warwick
  • Ms Samantha Walker, Lead Nurse – Infection Prevention and Control, Countess of Chester Hospital NHS Foundation Trust
  • Mrs Indu Das, Antimicrobial Specialist Pharmacist, East Cheshire NHS Trust

 

The second day had workshops on Antimicrobial Resistance (AMR), Antimicrobial Stewardship (AMS) and Infection Prevention and Control (IPC), with a fully engaged hospital team who gave frank and honest opinions about their hospital IPC practices and improvements needed. Workshop evaluation provided invaluable information that was consistent with observations.

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On the Saturday, we visited the hospital to get a sense of the out-of-hours services [accident and emergency and out-patient departments (OPD)]. We used this opportunity to review OPD antibiotic prescriptions of the day (revealing interesting findings).  We visited three community pharmacies within walking distance of LEKMA Hospital who had been informed of the project and were fully engaged in completing a knowledge, attitude and practice survey.

We spent the Sunday recapping and reflecting on the previous days’ events in the idyllic setting of Sogakope. Even on our day off, the team could not help but be productive and were able to record a podcast, prepare a WHO grant application for implementing delayed/back-up prescribing at LEKMA Hospital and learn about Ghanaian music.

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Monday was the advisory committee meeting, chaired by Prof. Afari. The morning of Tuesday 18th June, was feedback session with the LEKMA management and Ghana Public Health Association (GPHA).

In summary we were able to deliver:

  1. Agreed and signed off a Memorandum of Understanding and ToR;
  2. Established an AMS Advisory Committee;
  3. Completed a Global Point Prevalence Survey;
  4. Completed a healthcare workers Knowledge, Attitude and Practice survey;
  5. Initiated IPC guidelines review based on the WHO infection prevention control and hand hygiene assessment tools;
  6. Initiated discussion around prescribing guidelines (national) with the view of having simpler and more accessible local prescribing guidelines, i.e. within the context of the National AMR Plan and Prescribing Guidelines;
  7. Initiated the discussion around laboratory data surveillance processes and regular production surveillance outputs, with a focus on drug-resistant organisms;
  8. Agreed to implement delayed/back-up prescribing in the out-patient department of LEKMA Hospital.

We left Ghana with nothing but fond memories of a magnitude that we could not put into words and look forward to our next visit to Ghana.

Blog written by Edwin Panford-Quainoo, Liverpool School of Tropical Medicine

The Faculty of Public Health Part B Membership exam is the final stage of the route to membership of the Faculty through examination, but by no means the last step of becoming a Specialist in Public Health. Examiners from across the UK and from all domains of Public Health develop scenarios to test candidates’ abilities to understand and explain public health concepts and respond appropriately to questions and challenges in various settings (examples are available on the Faculty website). As examiners, we are committed to maintaining the standards set by FPH, but also committed to developing the next generation of Public Health leaders as excellent communicators and experts in all aspects of Public Health.

I was asked to write this blog, on behalf of my fellow examiners, after I had tweeted some tips based on reflecting on performance in the exam. One of my Registrars wrote a blog on how to prepare and pass the exam – this blog gives the examiner perspective.  As examiners, we wrote an article to help highlight how best to approach the exam. We had become concerned that some candidates are developing an approach to the exam which structures their answers but reduces their chance to succeed. These tips below, buidling on the tweets, are offered to all candidates with the reminder that, as examiners and colleagues: we want you to pass!

  1. Prepare to listen, hear the question, answer in a way that makes sense to that person, be it Director of Public Health (DPH), journalist or MP.

Too many candidates enter the room with their first answer prepared- forgetting to listen to the question. In a role play, examiners are keen to see that you are responding appropriately to the audience and answering the issues they raise. It is better to focus on listening to the question and answering the way you would in real life. Candidates are sometimes so determined to introduce themselves (which is not necessary) that they miss the first question altogether.

  1. Be ready to present/explain tables and charts – it’s what we do – but remember your audience. Don’t treat the DPH like you would a lay person.

If there are tables and charts in the pack, it’s likely you will need to understand what they say, and demonstrate this. This is a core skill of Public Health and we expect this to be done well. A trap some candidates fall into is in guessing the next question: “would you like me to explain confidence intervals” to which a reasonable reply might be “of course not- I’m your DPH!”

  1. Let the role player ask their questions. The pack doesn’t give you the structure, the questions do. Let us lead you through.

There are significant numbers of candidates who struggle because they don’t understand the format of the exam. The role player has a list of questions that they ask in order. These should elicit the information we need to mark the candidate. In general, scenarios are designed to build – so that the role play makes sense. Offering to give a speech, trying to tell us information that has not been requested, and answering questions you wish had been asked are all ways to run out of time and fail to complete the station.

  1. Don’t be just anyone – speak with passion about public health principles. Care about outcomes, inequalities and efficiency.

This is a “show’s how” exam where we are looking to see you have internalised Public Health concepts. Great candidates engage with the role play and come across as advocates for Public Health. This is far better than the trite “This is an important public health problem” statement repeated at every station by some candidates. There are no marks available for this.

  1. Have a good look at any data. Is it numbers, rates, percentages?  Be clear when explaining or answering questions.

Sometimes the scenario makes clear that the data has come from a poor quality source; a student project or similar. Might this mean that there are errors in the data? It’s vital that we use the right terms; confusing number of deaths with death rates is a sign a candidate hasn’t studied the material. Be accurate – the difference matters.

  1. Check the role player is understanding you. Keep eye contact- sometimes role players will look confused or upset- this is part of the station.

There is little scope for conversation in most scenarios- sometimes we really have to rush to get through the questions. Taking notice of how role players respond is an important part of the exam. Picking up on responses is a key skill in the “listening” competency. If you are asked the same question twice, it usually means its important and you did not answer it correctly the first time. Don’t try and skirt round it or just repeat what you said the first time.

  1. If you have to explain a table or graph – share it, show me, point it out.  Be sure I understand your explanation.

Great candidates really do this well. Positioning themselves in a way that allows them to share their papers, point at the information they are describing, and looking at the role player to see if they are understanding the explanation. Done badly, it can appear that candidates are just hoping not to be asked about it.

  1. Be ready to say if you don’t know. No “I’ll email you” or “I’ll get back to you”, sometimes you just don’t know – that’s ok.

The issue with the answer “I’ll email you” or similar is that the question has been asked and needs to be answered. If asked “Do we need to close the shop?” the possible answers are Yes, No and I don’t know. All can be valid, and the mark scheme will make this clear. The questions are scripted to last 8 minutes and the role player strives to complete the station within that time. Sometimes a scenario runs faster and most candidates finish a station a minute or so early. It will be obvious from the role player that the scenario is complete. It is quite okay to use this spare time to look at your next scenario.

  1. Remember to make eye contact. It’s a conversation.  The examiner role players are willing you on. 

Some candidates have clearly not prepared the “acting” side of the exam. Great candidates have a real conversation and engage the role player. This means they pick up on the mood and responses as well as the substance of the questions. Comments like “I know this must be difficult” and “I can see why you might think that” often reflect an understanding of the other point of view.

  1. Be yourself. You have got this far because of who you are.  Serious people think you are amazing.  Show us why.

We really do want you to pass. Many examiners are also Educational Supervisors, they are all involved in training and want to give candidates the chance to shine. We don’t want an act – just you being your best you. Read the material, listen to the questions, engage in the scenario and show us why one day soon, you will be a consultant.

 

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