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Archive for May, 2014

The damaging separation of public health from clinical service delivery

Posted in Uncategorized on May 23, 2014| Leave a Comment »

  • Dr Veena C Rodrigues
  • Clinical Senior Lecturer and Head of Year 3 MBBS
  • Norwich Medical School

I have only recently made the transition from ‘lurker’ to ‘active user’ on Twitter. Recently, I found myself following a talk by Dr Jeremy Farrar, Director of the Wellcome Trust via live-tweets from a London meeting for clinician scientists in training (Nurturing the next generation of medical researchers). Dr Farrar cited three challenges to UK science:

(1)    bringing young people into science and finding ways to keep them there;
(2)    addressing the divide between the clinical and research communities and encouraging them to work together; and
(3)    tackling the damaging separation of PH from clinical service delivery.

As a clinical academic in public health medicine (PHM), the last two points resonated strongly with me.  I have held joint academic-service roles in PHM right through specialty training and into my Consultant role. Core to such a role was the need to bridge the gap between academia and the service setting, not only to work efficiently and flexibly across the two, but also to ensure that the skill set developed and enhanced in one role was utilised clearly to benefit the other.

In my case, my clinical academic skills of research methodology, critical appraisal and evidence-based medicine were ideally suited to needs assessments, priority-setting, service specification and clinical policy development, clinical engagement with provider Trusts, evaluation of cost-effectiveness of services at my Primary Care Trust (NHS) employment.

Similarly, my local service provision experiences enabled me to pull out of my tool box examples and anecdotes to liven up any teaching/ training sessions in my educator role. You must remember we are talking about integrating PHM into undergraduate medical education, which is a daunting challenge: ask any UK medical school public health educator! I also had first-hand knowledge and experience of the service setting to inform the writing of research proposals to apply for grant funding, etc.

It is easy to assume that clinicians and scientists would work together naturally but at a time when healthcare provider organisations face increasing scrutiny in terms of meeting targets for service provision, service priorities often trump teaching and research. Addressing this widening divide in the face of conflicting organisational priorities is likely to be challenging but crucial for nurturing the next generation of medical researchers.

The NHS reorganisation following the Health and Social Care Act 2012 resulted in public health departments being moved out of the NHS and into local authorities (LAs). While the advantage of joint working between public health and local authorities to improve and protect the health of the population cannot be underestimated, the benefit of this conscious coupling to local clinical service delivery is much harder to visualise.

Relationships that had been built after years of committed and painstaking nurturing of the clinician/provider-commissioner relationships through clinical dialogue facilitated or led by PH specialists were suddenly stripped away resulting in another layer of bureaucracy (albeit with a ‘core offer’) diluting the relationships between the two organisations (1).

The public health emphasis on health needs assessment, priority setting, fairness, equity, appropriate and effective commissioning in the face of budget restraints. Monitoring and evaluation of services is likely to vary in breadth and depth across the country. It is dependent on whether local authorities have kept local structures in place and the level of commitment of the local authorities to health/ clinical service delivery. A postcode lottery?

A recent publication confirmed that local authorities across England are diverting ring-fenced public health funds and scaling back staffing to plug funding shortfalls caused by government budget cuts (2). It has also been reported that despite a mandatory requirement for Health and Wellbeing Boards to provide public health advice to local clinical commissioning groups (CCGs), sufficient public health input into NHS services to is lacking. This is at a time when CCGs are struggling to balance quality improvement and financial equilibrium (3).

Following the NHS reorganisation in 2013, public health clinical academics and researchers who had honorary clinical contracts with local NHS organisations (PCTs) lost their clinical (NHS) links when the hosting of these contracts moved to PH England, a new non-NHS organisation, still struggling to establish its mark (4). This resulted in the formal separation of a link between academic and service public health that had facilitated joint working, making it nearly impossible to influence the work of local CCGs without getting embroiled in convoluted management links and processes.

So, you might well ask: where does this leave healthcare public health? It is difficult to predict the future but if the government is listening, please could you strengthen the requirement for local authorities to have an appropriately skilled public health workforce to provide adequate input into local NHS services? Supporting the work of CCGs towards effective and cost effective local health services commissioning is after all a key part of the standards for delivery of public health within local authorities! (5)

And pretty please, could you also restore public health academic-service links especially for clinical academics? I am fast running out of new examples to give my medical students to emphasize the clinical relevance of the public health curriculum.

References:

  1.   Department of Health. Guidance on the healthcare public health advice (core offer).
  2. Iacobucci G. Raiding the public health budget. BMJ 2014; 348: g2274.
  3.   Furber A. Public Health: what has worked, what hasn’t, and what’s next? The Guardian, 5th April 2014.
  4.   UK Parliamentary Health Committee. Public Health England: Eight report of session 2013-14. London: The Stationery Office Ltd, 2014.
  5. FPH. Standards for Public Health, 2013.

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“Why are we not more angry?”: Sandwell Health’s Other Economic Summit (SHOES), March 2014

Posted in Uncategorized, tagged , , , , on May 13, 2014| Leave a Comment »

  • by Miranda Eeles
  • Researcher at London School of Hygiene & Tropical Medicine

“Why are we not more angry?”

That was the question being raised by the participants of Sandwell Health’s Other Economic Summit (SHOES) which brought together academia, doctors, architects, journalists, local government and civil society to discuss issues ranging from sustainable food policy and climate change to the privatization of the NHS.

The Summit, which was held at the Balaji Temple in Tividale on Friday 28th March, is Sandwell Health’s annual event that aims to explore current themes and challenges in public health both at global and local level.

Neo-liberalism, corporate power and an assumption that development equals economic growth were identified as some of the mains reasons behind the problems facing the world today, and the increasing gap in inequalities.

“We need to change the narrative”, said Dr David McCoy, senior clinical lecturer at Queen Mary University, London and Chair of MEDACT.  “We need to demonstrate an alternative system and put forward intellectual and scientific arguments to eradicate poverty and address climate change.”

Corporations, government and the insurance industry were all put under the spotlight as speakers lamented a lack of leadership across the party spectrum.

But as in previous SHOES events, the audience also heard about the achievements at local level which illustrate how change can happen, provided the political will is there.

Urban food growing, investing in community assets and young people, creating a culture of activity and a return to a strong synergy between rural and urban environments were listed as some of the ways in which to address local needs.

This year’s Summit also was a celebration of the exemplary work done by John Middleton, Sandwell’s Director of Public Health, who retired at the end of March after 27 years in the job.

‘Dials’ and ‘levers’ were terms used to describe priorities and actions that have been employed under his leadership to bring different agencies together to improve the health and well being of the local population, including the Police, NHS Trusts, Clinical Commissioning Groups, a Youth Council and different departments of Sandwell Council.

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Sandwell public health – my life course

Posted in Uncategorized, tagged , , , , , on May 13, 2014| 1 Comment »

– by Dr John Middleton

–  Vice President, Faculty of Public Health; formerly  director of  Public Health for Sandwell, 1988-2004

When I first came to Sandwell in 1987 it was in the depths of recession. In health services there was no local mental health service, no palliative care and much general practice was single-handed out of shop fronts. Waiting lists for basic elective procedures could be up to four years. Over half the population was living in poverty. There were 120 high-rise blocks and nearly fifty thousand council houses. Less than half of all children were immunized against measles and other childhood immunisations were less than satisfactory.

There have been great advances in health and health services provision. Progress began in the early 1990s and became exponential in the early 2000s.  Even nine-month waits for operations were no longer to be accepted. They had to come down to 18 weeks. And no more than 4 hours in A&E.  Services for people with serious and enduring mental health problems were improved substantially in the early 1990s. Over many years there have been improvements in community based palliative care, with fewer people dying in hospital.

In my final annual public health report for Sandwell, ‘ Public health: a life course’, I have reflected on some improvements in outcome.  Heart disease deaths have gone down by an astonishing 2/3rds. Some of this is reflected in the long-term trends. But those trends have been influenced by the new and evidence based services, which have been implemented across the country over the years. We can point to improvements made in Sandwell, which have reduced deaths faster than the national rate and have reduced our gap in life expectancy with the national rate. Most recently, our GP based risk management system has saved more than 70 lives a year and closed the gap with the national life expectancy. Not a bad result considering heart disease deaths went up in the mid 2000s.  I believe this was a cohort effect. The group of men thrown out of work in the 80s were dying prematurely from heart disease, brought about by a lifetime without work, hope, and probably smoking, drinking and being inactive.

Teenage pregnancy has come down by 44% since 1998. This I attribute principally to rising expectations in education. From 2007, exam results went up and teenage pregnancy came down. Over a number of years, it ceased to be acceptable to attribute poor results and low expectations for our children to  ‘the deprivation’. If one teacher, or one school could make a go of educating children under difficult circumstances, they would all be expected to.  In health, there were also some excellent services built up painstakingly over a number of years, in personal social education, young people’s contraceptive services and morning after pill availability from pharmacists.

The fact that teenage pregnancy has not gone up again in the latest recession is, I think, due to the insulating effect of the Surestart programmes, which began in 1998. Surestarts gave support to parents from deprived backgrounds, Surestart plus gave additional support to teenage mothers and Surestart maternity grant gave some financial support to pregnant mums.  Most recently the Family nurse partnership has provided additional support to young mums. The policy advisory team from cabinet office that came to Sandwell in 1998 expressly set out the idea to support teenage mothers at that time, to break the cycle of babies born to teenage mothers then, becoming themselves teenage mothers 16 years on, I think we are seeing the benefits of that.

There has been an outstanding achievement in improving  Sandwell homes to Decent homes standard. In our local research which we plan to publish,  we have found much larger health effects in reducing cold related deaths and hospital admissions than have previously been reported.

There has also been the excellent achievement of Sandwell probation service in having the lowest reoffender rate in the country.  The health component of crime reduction this has been considerable- in tackling drug and alcohol related crime, responding to domestic violence, providing appropriate care for mentally disordered offenders and supporting community development programmes to combat violent extremism.  The recovery agenda for drugs and alcohol related offences has been a substantial contributor to reducing reoffending.

On a downside, there is much for my successor Jyoti Atri, to pick up on and deal with. Tuberculosis rates remain stubbornly and unacceptably high.  It is normal to be overweight in Sandwell.  Infant death rates have not reduced in the last 15 years. The West Midlands has the highest perinatal and infant deaths in the country and they have not come down as fast as they have elsewhere. The West Midlands has the highest rates of child poverty and the highest rates of obesity in the country both known risks in terms of infant health outcomes. We  also need to review our antenatal policies, particularly with regard to growth monitoring in utero. I have recommended that Sandwell should commission an expert review of infant deaths, preferably with other councils in the West Midlands conurbation. The review would look at how we should prevent deaths, and what might be needed in improving care in pregnancy and childbirth.

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