Better Health For All

• by Lorraine Lighton, outgoing CPD Director at FPH

As my term as Director of Continual Professional Development (CPD) for FPH draws to a close, I’ve been reflecting on how the FPH CPD scheme has developed during the last four years and how much I’ve learned about the process of continuing professional development.

There have been substantial changes to the CPD policy and guidance in recent years to make it fit for now and the future. None of this could have happened without the amazing support of the Faculty staff, especially Krisztina, Audrey and James, and the CPD Advisers who work with me to develop policy and guidance and who act as auditors.

One of the highlights of my time in office has been the development of guidance on writing reflective notes. This was produced by a small sub-group of CPD Advisers and has been commended by the General Medical Council.

Why do we place so much emphasis on reflective notes? One of the great strengths of the FPH CPD policy is that it recognises that there are many ways of learning, not just attendance at training events where certificates are handed out. Because FPH accepts such a wide range of activities as CPD, for which formal evidence such as test results or certificates are not available, we need a different form of evidence and that is what reflective notes are partly about.

They have the added bonus of making us think about the activities we have undertaken, what we learned from them, how our practice may change as a result, and what further learning we may need, thus developing us as reflective practitioners. Members of the FPH CPD scheme will recognise that this is the basis for the ‘Four Questions’ on the CPD record.

FPH audits a selection of CPD records every year as part of its quality assurance. As Director of CPD, I am that scary person who makes the final decision if an audit submission is deemed unsatisfactory. I know how it feels to be audited and the anxiety of waiting to find out if you have ‘passed’. We have responded to members concerns by speeding up the audit process and bringing it forward, so that members have plenty of time to improve their documentation for the following year if they didn’t meet the standards.

Although auditing is a substantial workload, it is never boring and has given me an overview of where members who struggle with CPD documentation go wrong. Here are my top ten tips to getting it right:
1.    Read the CPD policy and guidance. It’s not a difficult read and will help you understand exactly what is required and what to do if you are having problems.

2.    Ensure that your Personal Development Plan is broad enough to cover a substantial amount of your CPD for the following year, but sufficiently focused that there is more than one line such as ‘Do CPD’. And yes, PDPs like that do exist.

3.    If you are having difficulty undertaking sufficient CPD (maybe you need help recognising that some of your on-the-job learning can be claimed), seek help early!

4.    If you have problems recording your CPD, seek help early! Don’t wait until the end of the CPD year to suddenly find that you don’t know how to use the online log, your written English is insufficient to write a few sentences about your experience of learning, or you haven’t had time during the year to record your CPD or develop a Personal Development Plan.

5.    FPH has a fantastic team of administrators and CPD Advisers who can direct you to guidance and if necessary find solutions, but you need to seek help early as soon as you identify a difficulty, not after you receive the dreaded letter advising that you have been selected for audit.

6.    You don’t have to be Proust to write a reflective note. We don’t need volumes of high literature. Have a look at the examples on the FPH website, which includes my own submission for audit (and I was always near the bottom of the English class at school). When composing a reflective note, I say it to myself as though I were talking to a colleague then write it down verbatim, but do whatever works for you.

7.    On the other hand, it is not really possible to show reflection in a note comprising less than 20 words in total for answers to all four questions. If you are unsure how to write a reflective note, read the guidance on the FPH website.

8.    Please don’t feel insulted by comments from the auditors. These are intended as a pat on the back (for high quality documentation) or as constructive criticism if there is room for improvement.

9.    Please don’t complain to the Faculty because you have been selected for audit two (or three or more) years in a row. In order to ensure quality control there has to be a random element to the selection, so some people will hit the jackpot more than others. We have made submitting for audit as easy as possible – you just need to click on the submit button. And if you have been keeping up to date with writing reflective notes, the whole process of submission should only take a few seconds.

10.    If your documentation is assessed as unsatisfactory at audit, DON’T PANIC. Follow the guidance from the auditors and you will almost certainly ‘pass’ next time.

The most important thing I’ve learned during the last four years is that CPD should not be seen as an unwelcome hurdle. The Faculty CPD scheme aims to help us become the best practitioners we can. So next time you are selected for audit, be pleased you are being given a chance to show off your reflections to your peers!

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• by Allyson Pollock, Professor of public health research and policy at Queen Mary University of London.

On 2nd March 2016, along with 70 other academics, doctors and public health professionals, I wrote an open letter to Ministers of Health, Education and Sport, Chief Medical Officers and Children’s commissioners in four nations of the UK, as well as the Republic of Ireland. We asked them to consider the evidence and remove the collision elements of rugby within British school systems, so that children play touch and non-contact rugby.

The UK government has selected rugby union and rugby league as two of five sports it will focus on to increase the prominence of competitive sport in schools It hopes to put 1,300 links in place between schools and rugby union organisations, and 1,000 links with rugby league, and wants to recruit one million school children to the game in England across 750 State Schools.

Our concern is that rugby is a high-impact collision sport with a high rate and risk of injury. Although there is no comprehensive injury surveillance in the UK, studies show that the risk of injury for a child rugby player varies from 12% to 90% over a season of 15 games, depending on the definition used.

A systematic review puts the average risk of injury at around 28%. These injuries include fractures, ligamentous tears, dislocated shoulders, spinal injuries and head injuries which can have short-term, life-long, and life-ending consequences for children.

The risk of concussion for a child or adolescent rugby union player over a season is 11% – that’s the equivalent of one or two players sustaining a concussion every season in every school or club rugby team of 15 players.

Contact is where the majority of injuries occur. Research also points to the tackle being a particular cause for concern. In studies of youth rugby, tackles were found to be responsible for up to two thirds of all injuries and 87% of concussions.

Given that children are more susceptible to injuries such as concussion, the absence of injury surveillance systems and primary prevention strategies in the UK is worrying. For far too long. The Rugby Unions have chosen to hide behind the lack of comprehensive nation wide data citing this as insufficient evidence meanwhile ignoring the evidence that has been collected over decades.

The four rugby unions of England, Scotland, Wales and Ireland have responded to concerns and criticisms with many initiatives, including concussion management protocols, but none have been evaluated. Furthermore, these initiatives are concerned with management of injury and not prevention and comprehensive injury surveillance has been relatively neglected.

Editor-in-chief of the British Medical Journal, Fiona GodleeEditor-in-chief of the British Medical Journal, Fiona GodleeEditor-in-chief of the British Medical Journal, Fiona Godlee, has called the current state of monitoring and prevention of rugby injury in schools a “scandal” and last year a BMJ poll of doctors confirmed that 72% felt the game should be made safer.

Injury prevention requires radical changes to the laws of the game. It means removing the collision element, namely the tackle. Martin Raftery, the medical director of World Rugby has stated that the laws of rugby may have to change to reduce concussion risk, but World Rugby is dragging its feet in dealing with the dangerous tackle.

The key problem is that it is the sport’s own governing bodies that determine the laws of the game for children. World Rugby determines the laws even at school level but its interests are in the professional game and business, not children. The link between the professional game and the children’s game should be severed – governance of the children’s game should not be determined by World Rugby and the Rugby Unions.

If the game is rolled out to one million school children in England, and the tackle and collision remains a part of the game, children will be left exposed to serious and catastrophic risk of injury, and on the basis of current studies the potential number of avoidable injuries could rapidly approach at least 100,000-300,000 a year.

Parents expect the state to look after their children when they are at school, they do not expect their children to be injured. However, neither parents nor children are given information on injury risks and causes in this sport.

Even more worrying is the fact that many secondary schools in the UK deliver contact rugby as a compulsory part of the physical education curriculum from age eleven – children and their parents do not have the option to opt out of a situation that risks bringing them serious harm.

Children who want to play the tackle version can always join a club, but they shouldn’t be forced to play contact rugby as part of the national curriculum when there is such a significant risk.

As a signatory to the UN Convention on the Rights of the Child, the UK and Irish governments now need to take all necessary steps to inform children and protect children from mental and physical injury and abuse and ensure the safety of rugby.  Injury surveillance and monitoring in hospital emergency departments and by schools must be a priority so that data on sports and other activities can be collected. Until the government can show that harms and injuries have been minimised it should remove the contact from the children’s game in schools.

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• by Alison Garnham
  
• Chief Executive
• Child Poverty Action Group
  • Hear Alison talking about why measuring child poverty matters

For campaigners, lobbying on bills can often be a frustrating experience.  You can have all the arguments, evidence and esteemed experts on your side, but if ministers don’t want to do something, then it’s very hard to make them do it.

So, we were delighted at the end of last month when sustained campaigning since last summer by the Child Poverty Action Group and others paid off. Following a defeat in the House of Lords, the Government announced that the Welfare Reform and Work Bill would be amended to include a statutory duty to publish child poverty statistics based on existing measures in the Child Poverty Act.

The Bill itself scraps legally binding targets to eradicate child poverty, which had been agreed just five years previously. Along with the targets would go the government’s duty to report annually on child poverty, and the requirement for national and local anti-poverty strategies. Campaigners, who five years earlier had celebrated the passing of the Child Poverty Act with cross-party consensus, reeled.

Until this volte-face by ministers, it was feared that the statutory annual measures of child poverty – part of a vital dataset for tracking the impact of policies on the incomes of households with different characteristics – would be lost too.

Why do the measures matter?

The government has been arguing against the child poverty measures, which capture various aspects of household incomes, for some time, claiming that to focus on money is to focus on the ‘symptoms’ and not the ‘root causes’ of poverty. It therefore sought to replace the child poverty measures with new measures of ‘life chances’, focusing on children in workless households and educational attainment at age 16.

These issues are certainly important, but they miss the fact that poverty is, at its heart, about not having enough money, and that almost two-thirds of children living in poverty have a parent in work.

The experience of living in poverty has many dimensions, but academics, professionals and the general public agree that lack of material resources is the main characteristic of being poor. And it is beyond doubt that poverty poses a serious risk to children’s life chances, with consequences for health, cognitive development, educational outcomes, social and emotional wellbeing which extend far into adulthood. A life chances strategy which does not look at poverty would be nonsensical.

It is also beyond doubt that the swathe of cuts to social security benefits, both those implemented since 2010 and the further cuts now going through parliament, will make children poorer. New projections suggest that child poverty will increase by 50% by 2020, due primarily to benefit levels falling away from the mainstream of family incomes. This has been termed the ‘biggest rise in child poverty in a generation’.

Many commentators wonder if the government is trying to hide the expected surge in poverty by quietly dropping the statistics. The government has certainly worked hard to discredit the child poverty measures, for example asserting that the measures incentivised previous governments to move households from just below the poverty line to just over it rather than making more fundamental inroads into poverty, an argument categorically disproved by IFS analysis.

We have four excellent measures of poverty, recognised internationally and based on decades of academic work and expertise, which allow us to understand the impact of policies and hold the government to account for changes in the fortunes of disadvantaged families. Between them these measures capture:
–    Relative poverty, to track whether the fortunes of a group of the population are falling behind or catching up with the mainstream, over time;
–    Absolute poverty, to track whether family incomes at the bottom end are rising or falling in real terms from one year to the next;
–    Poverty with material deprivation, to track what is happening to standards of living and ability to afford the essentials; and
–    Persistent poverty, to track how likely families are to be stuck in poverty year after year.

For anyone concerned about poverty and the life chances of the current generation of children, it is vital that this information base be maintained.

The campaign

A huge number of charities and other experts spoke out against the changes. More than 175 academics and health, education and social work professionals signed letters to the Times and the Guardian. 50,000 members of the public signed a petition started by a mum with experience of struggling to make ends meet. Blogs were published, briefings were given to MPs and peers, and hundreds of people wrote to their MPs and members of the House of Lords. Parliamentarians launched inquiries, gathered evidence and published hard-hitting reports. Peers and MPs spoke passionately and convincingly in a series of debates, presenting a raft of evidence and expert opinion which all pointed to preserving the child poverty measures.

In the end, the government agreed to commit in law to publishing these statistics annually. By giving the poverty statistics prominence in the Life Chances Act, it has also acknowledged the importance of family income to life chances. We hope this will be reflected in the life chances strategy due to be published in the coming months.

What now?

Securing the measurement of child poverty is a big win, but measurement is not the same as action. There will be no legal obligation on the government to take steps to reduce child poverty, even though action is urgently needed. The government will be obliged to publish these statistics, but not to provide an official report on them. This means that it will be for those outside government to make sure that attention is still given to these figures, and the impact of policies on poverty investigated.

But this success will mean that any movement in poverty levels, whether up or down, will be in full public view, permitting rigorous analysis of what is driving change, and a generation of children will not be whitewashed from the record books.

As Rebecca, the mother who launched the petition to save the measures, asked: ‘Children in poverty already feel poor and disadvantaged, why should they also be unnoticed’?

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• by Serena Luchenski, Public Health Registrar, Health Education Central and North West London

The Chief Medical Officer’s Academic Fellowship has been a fantastic opportunity to cultivate my skills and knowledge in Homeless and Inclusion Health research.  Since April 2015, I have been based in the Department of Public Health Informatics at the Farr Institute of Health Informatics Research at University College London. My experiences this year have been exciting, varied, and have provided me with many new learning opportunities that will surely benefit my future public health career plans.

My main reasons for applying for the CMO fellowship were to develop my research network, to improve my academic profile, and to apply for a PhD. I have known for a long time that I would like to incorporate research into my public health career, but I had not found the right opportunity or dedicated time for making that happen. With my Fellowship drawing to a close in a month or so, I am amazed at all of the opportunities I have had over the last year. Below are a few of the highlights and my plans for what’s next.

Publications
I led a review of ‘what works’ in Inclusion Health to provide an overview of interventions that impact health and the social determinants of health for people with experiences of homelessness, drug use, imprisonment, and sex work.  I collaborated with several national and international experts from organisations including Pathway, Find & Treat, and the International Street Medicine Institute. The paper is part of a commissioned series and is currently under review at the Lancet.

I also had the opportunity to complete a previous research study that I did in Vancouver, Canada working with people who use drugs.  It was recently published in Drug and Alcohol Review, “Protective factors associated with short-term cessation of injection drug use among a Canadian cohort of people who inject drugs”.

This paper demonstrates the relative importance of the social determinants for promoting behaviour change – housing, employment, social support, and access to services were all found to be more important than addiction treatment in promoting cessation of injection drug use.

Conferences
I gave two oral presentations at the Lisbon Addictions Conference, one on my paper about cessation of injection drug use and a second on engagement with people who use drugs for harm reduction planning and policy (paper under review). It was a great conference and I met many new colleagues from the UK and across Europe.

I also helped to organise the Lancet UK Public Health Science Conference and co-chaired a very exciting oral paper session with the Lancet editor-in-chief, Richard Horton.  In March, I will be attending the Homeless and Inclusion Health Conference in London, which is a must-attend for anyone interested in this topic.

Patient and Public Engagement
As part of the Inclusion Health review, I developed new expertise in patient and public engagement. I organised a workshop with people with lived experiences of homelessness and social exclusion who volunteer as ‘peer advocates’ at a homeless health charity called Groundswell.   The workshop enabled me to provide context to the findings of the review paper and it has helped me to develop my future research plans.  I also discovered that I really enjoy public engagement and facilitation.  I have been invited to lead events or teach on several occasions off the back of this first workshop.

Teaching and Advisory Roles
I gave an exciting lecture on social determinants and homelessness to medical students where I presented alongside a group of experienced homeless health peer advocates from Groundswell. This was an enlightening teaching experience – I delivered the theory and the peer advocates shared their personal experiences. I am not sure who learned more – me or the students!  I also taught about social determinants theory to trainee homeless health peer advocates and was invited to join an expert advisory panel for an external evaluation of the Groundswell service.

Training Courses
I undertook an intensive course on Applied Research Methods for Hidden and Marginalised Populations at the University of Essex. This course was really interesting because there were attendees from many different areas of the world, and spanning disciplines from public health to conflict, migration, and child trafficking. I have already applied some of the methods that I learned during this course in my public engagement activities.

Future Plans
My Fellowship has allowed me to build a strong, interdisciplinary network of academics and health professionals from multiple organisations across the UK and internationally. I am planning to undertake a PhD when I complete my Public Health Training and I am presently preparing a PhD Fellowship application to improve preventative healthcare for people who are homeless. In the future, I hope to join up both of my passions for academia and public health service to become a leader in Inclusion Health research and practice. My Academic Fellowship year has been a catalyst for achieving these career aspirations.

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