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Archive for October, 2018

Dr Julian Tudor HartThe colossal contribution of Julian Tudor Hart to primary care and Public Health was recognised in a series of obituaries in the media after his death in July. He started a Welsh Valley GP practice in the 1960s and has since been described variously as a visionary, an advocate for social justice, a prodigious scientist, a great thinker, a pioneer of primary care and a true giant of the NHS. In 2006 he was also awarded the Discovery Prize by the Royal College of General Practitioners (RCGP). His nomination read: “His ideas and example pervade modern general practice, and remain at the cutting edge of thinking and practice concerning health improvement in primary care.”

Without a doubt he has been a major influence on public health thinking for decades and I would like to describe the impact Julian Tudor Hart has had on my work.

I grew up in the back streets of Halifax and was fortunate to take advantage of some social mobility opportunities and gain entry to a London medical school. I returned to the deprived areas of Halifax to train in General Practice and here I came face to face with the immense social problems interwoven with health symptomology presenting to general practitioners. It was during my GP training that I first came across Julian Tudor Hart’s research and began to draw connections between social factors and health and develop a public health mind-set which shaped the rest of my Public Health career.

A couple of decades ago, I used Tudor Hart’s thinking to establish systematic and structured care for CVD through disease registers in South Staffordshire, well before the National Service Frameworks (NSFs) were introduced. It is remarkable how advanced Julian Tudor Hart’s thinking was in introducing opportunistic screening, and structured or ‘anticipatory’ care and practice nursing in the 60’s and 70’s. Today, post QOF and the NSFs, we still have unacceptable health inequalities in managing long term conditions in primary care as evidenced by the data from Right Care.

I moved to Stoke-on-Trent in 2006 and set about transforming primary care in one of the most deprived areas of England blighted by decades of post-industrial decline, poor housing and lack of employment opportunities. The rationale being was that these populations need not just good or average quality of primary care but the best primary care possible.

We set about defining what excellent primary care would look like and my first point of call was to search words of wisdom from amongst the 250 research papers Julian Tudor Hart published. We developed an exemplary primary care model which aimed not only to provide the best medical care but also to promote holistic public health and community asset-based approaches. This attracted some national attention and we organised a number of events. I asked Julian if he would be willing to come as a special guest but he reluctantly declined as by then he had considerably cut back his external commitments.

Without doubt Julian Tudor Hart has been a great source of inspiration for me and shaped my Public Health practice. I would like Julian Tudor Hart not only to be on the reading list of every future aspiring Public Health specialist and GP trainee but should be  pre-requisite reading for every new Secretary of State for Health, too. Maybe we would then see a health and social care system designed to reduce health inequalities.

Written by Professor Zafar Iqbal, Associate Medical Director Public Health, Midlands Partnership NHS Foundation Trust.

 

 

 

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In collaboration with the Journal of Public Health (JPH) and the Primary Prevention of War Working Group, the Global Violence Prevention special interest group (SIG) is pleased to invite you to submit papers for a special JPH supplement on the subject of ‘Armed Conflict and Public Health’.  All papers included in the supplement will be both free-to-publish and free-to-view online.

The public health impact of armed conflict is a rapidly developing academic field, with widespread interest driven by current events and being expressed across a range of different stakeholders including NGOs, military, political and public community-level groups. The Global Violence Prevention SIG was set up by the Faculty of Public Health in 2016 in order to apply a population health lens to the issue of armed conflict.  The organisational relationship between FPH and JPH has raised the possibility of co-producing a special supplement on this timely and important issue.

A prestigious team of guest editors, including Professor Jennifer Leaning of Harvard University, Dr Karl Blanchet of the London School of Hygiene & Tropical Medicine and Dr Mohammed Jawad of Imperial College will be overseeing the content of this supplement, which is expected to be published in August/September 2019.

We encourage the submission of any original articles which take a public health approach to the issue of armed conflict. Topics of interest could include (but are not limited to):

  • Health consequences of forced displacement
  • Environmental impacts of war
  • Social & community cohesion effects of specific conflict(s)
  • Public health impacts of different weaponry/tactics
  • On-the-ground case studies or perspectives from authors in conflict-affected countries
  • Child development in warzones

The deadline for paper submission is 31 January 2019.  Please refer to the JPH information for authors guidance in preparing your manuscript and email submissions to Andrew.Elias@oup.com with the subject ‘Conflict & Health supplement’.

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In light of our wish to encourage authorship from conflict-affected countries, it may be possible to arrange for experienced academics to offer either mentorship or co-authorship to potential authors who have first-hand research or perspectives to share. Enquiries about this should be directed to daniel.flecknoe@nhs.net. If English is not your first language then please refer to the OUP guidance and support on academic English.

Written by Dan Flecknoe, FPH member and Chair of FPH’s Global Violence Prevention SIG. You can follow Dan on Twitter @dannyflecknoe.

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Rachel Thomson is a third year specialty registrar from NHS Ayrshire & Arran in Scotland, currently on a six month attachment with the FPH Policy and Communications team. She has agreed to keep a regular blog during her placement, to provide a window into the work of the Policy and Comms team and inspire other registrars to follow her lead! In this second entry she marks the halfway point of her attachment discussing what she’s achieved so far, and what’s still around the corner.


I’ve now been working with the FPH policy team for just over three months, and I can honestly say that it’s flown by. Most of that time has involved remote working from Glasgow, but I’ve been able to travel to London to work from the office for a few days about once a month so far. Making that in-person connection with the team (and the other registrars working on the policy campaigns) has really helped solidify our working relationships, and given us plenty of opportunities to make sure we adapt my work plan to meet my training needs.

As I mentioned in my last blog – and as you’ll have seen if you follow either me or FPH on Twitter – my biggest focus so far has been on launching and running the #PublicHealthLooksLike photo competition. It’s a crucial part of the wider Public Health Funding campaign: we want it to generate a diverse range of inspiring photographs showcasing the hugely meaningful work occurring daily within public health, helping to make the case for its importance in an innovative and visual way. No pressure then!

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#PublicHealthLooksLike: I helped to design this Twitter banner to promote the photo comp

A couple of weeks ago, I got the chance to present a competition update to the Public Health Funding Campaign Advisory Board, and I made it clear that we’ve been overwhelmed with the level of engagement from members and non-members alike. We’ve had such positive responses from across the public health community and others I’ve approached to help disseminate information about the competition, including universities, arts societies and public health networks. I’ve also had a great time seeking out potential entries on Twitter – the number of people online who don’t necessarily realise what great amateur photographers they are is incredible! – and we’ve had a fantastic number of high quality entries as a result.

By the time this blog goes live we’ll probably have passed the deadline to enter, but I wanted to take this chance to personally thank EVERYBODY who’s gotten involved to help spread the word and support the competition over the last couple of months. You’ve made my job so much easier, and in doing so I hope you feel that you’re helping FPH more effectively tell the story of what public health means to all of us today. Please do follow up that support by voting for the winners when the 20 shortlisted entries are circulated to the membership next month!

Alongside the closing stages of the photo comp, my next move is into the world of design and publishing, with the planning and implementation of a special edition eBulletin updating members on the work of the Public Health Funding campaign so far. It’s early days with this, but I want to pull together something that properly represents the huge amount of work the policy team have put into the campaign so far – even having been involved for only a short time, I can see that it has the potential to really affect change, adding to the evidence base and call for improved funding of public health services in the UK. I’m thrilled to be part of that, and to have the chance to champion it to all FPH members in the coming weeks – look out for the special eBulletin landing in November.

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I was given the opportunity to speak to the new cohort of registrars

Finally, one of the many extra fun things I’ve had the opportunity to do as a result of this attachment is attend the induction day for new public health registrars on 3 October, where I gave a short presentation about what it’s like to undertake an attachment with the FPH policy and comms team. It was great to see and meet some of the next generation of public health professionals. Hopefully some of them will have been at least a little inspired to follow in my footsteps and take up an opportunity like this in the future!


Written by Rachel Thomson, specialty registrar and member of FPH’s Public Health Funding project group. You can follow her on Twitter @rachel_thomson. If you’re a Specialty Registrar, want to get comms experience that will help you achieve your learning outcomes and are interested in joining our Project Scheme, click here for more info or email policy@fph.org.uk to find out how you can apply. Please note that applications to apply for a comms role will be opening soon.

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Gus headshotI’m excited to be writing my first blog for FPH. Please be gentle with me!

We’ve just posted our new Prevention Transformation Fund discussion paper on our website.

The discussion paper is the result of a lot of consultation with public health experts over the past nine months.

We’ve talked with our members, most of whom are public health professionals doing brilliant work to improve the health and wellbeing of their local community and prevent a worsening in health inequalities.

But we’ve also sought out the views of partner organisations, health think tanks and those in statutory bodies to find out what they think the public health community needs most to undertake the ‘radical upgrade’ in prevention that has been talked about for many years but, so far, hasn’t materialised.

The main challenge we’ve encountered in developing FPH’s Prevention Transformation Fund policy idea is whether a transformation fund is really needed at all. A minority have argued that we should simply be making the argument for reversing the public health funding cuts faced by public health teams across the UK.

We recognise a number of very well-respected public health organisations and charities will likely make this argument during the forthcoming spending review consultation process.

It is a very finely balanced discussion but our view – based on all the conversations we’ve had so far – is that a temporary (five-year), targeted injection of funding, principally to support innovative projects or interventions we know work and that need upscaling quickly, is what local public health teams need most right now.

This temporary injection of funding will give time for other measures, notably a ramping up of prevention activity through the forthcoming NHS 10-year plan, to be realised.

It will also give further time for a ‘health in all policies’ approach within local councils to blossom. And it would allow for any change in the ring-fenced public health grant approach to bed in.

But what do you think?

What is without doubt is that local public health teams across the UK cannot take more cuts without it having a very serious and negative impact on the future health and wellbeing of local communities, on NHS and social care services, and on our economy.

And this impact would be felt at a unique moment in our country’s history when we really really need the UK population to be ‘match-fit’ for Brexit.

While many in the public health community are – perhaps understandably – pessimistic about our chances of securing new funding next year, we are approaching the spending review with both the Prime Minister and the Secretary of State for Health and Social Care having publicly stated that prevention must be one of a small number of key priorities.

This may indicate that making a compelling case to the Treasury for ‘how’ to inject new prevention funds into local communities and being able to convincingly model how this will lead to a respectable and timely return on that investment, may be more important than making the case (again) for ‘why’ we should invest more in prevention services. Although it is worth stressing that both the case for ‘how’ and ‘why’ need to be made clearly and convincingly.

As the name suggests, we’re hoping our discussion paper will encourage more conversations across our membership and with the public health and wider health communities.

You can read the full discussion paper, written by Senior Policy Officer, Lisa Plotkin, here. Please do let us know what you think.

And if you’re an FPH member and want to play a bigger role in our Public Health Funding Campaign, please consider joining our membership ‘sounding board’.

Let us know what you think about our discussion paper and find out more about how to join our campaign ‘sounding board’ via policy@fph.org.uk

Written by Gus Baldwin, director of policy & communications at FPH. You can follow Gus on Twitter @Gus_Baldwin.

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Two linked but separate pieces of work are being undertaken on the administration of the Part B Membership of the Faculty of Public Health (MFPH) examination. Firstly, a review of the application policy and procedure for the Part B MFPH examination led by Dermot Gorman. Secondly, an option appraisal of approaches to flex the annual capacity for the Part B MFPH examination. The examination itself is not changing.

The task and finish group looking at renewing the policy and procedures for Part B MFPH are considering the cancellation policy, early confirmation of place allocation, priority waiting list and fast track procedures. When I asked Dermot to lead the work I was clear that the critical thing was to get it right, that is acceptable to all stakeholders, rather than completed quickly. The group’s original proposal which was considered by the Education Committee in August was not acceptable to registrars, but I hope that the Education Committee will be able to unanimously approve an amended proposal in November to enable implementation this year.

The 2019 Part B MFPH examination sittings are heavily subscribed, and as a consequence FPH have scheduled an additional fifth sitting. This, however, is very much an exception based on apparent demand and may well run at a loss for FPH. The inclusion of an exceptional fifth sitting in 2019 does not set a precedent for future years.Most registrars who have passed the Part A MFPH examinations on or after January 2017 have now applied for the Part B. The Faculty have always routinely scheduled four Part B examinations per year giving capacity for 96 candidates, and on every occasion in the past when a fifth sitting has been added it has led to the cancellation of a subsequent sitting because of insufficient demand.

The issue with waiting time is the result of small number variation; the number of registrars recruited varies slightly each year as do pass rates for both examination. The only option to date for increasing capacity has been to add a sitting, but this adds 25% more capacity in a year which to date has been larger than the demand.

Personally for me the most significant consequence of unfilled examination places, even if as I hope the new policy and procedures for Part B do not require cancellation, are not the extra cost but the impact on our examiners. These unpaid volunteers are the unsung heroes of the Faculty, who do not get the thanks they deserve. Not only do they have to write, test and quality assure additional examination material but they have to travel and often stay away from home to deliver the examination. So thank you Faculty Examiners.

The fees for the Part B examination in 2018 are £875, but the cost of delivery of each place is £950 if all places are filled and it is not necessary to use more than one place to enable reasonable adjustments. The difference which in practice is actually greater is subsidised by membership fees.

I have set the Faculty staff a very tough challenge. Is there a way to increase the capacity of a Part B MFPH sitting without increasing cost? The ability to both flex capacity and minimise examination fees would be a prize well worth having.

This is not as easy as it as first seems. The current circulation of 12 candidates through a morning session of the Part B examination is timetabled as follows:

Photo 1 for blog

Cohorts of six candidates have a slightly staggered start and the timetable allows for eight minute preparation for candidates before each examination station. The afternoon session mirrors the morning with suitable adjusted times.

Potential Alternative

It is common to use rest stations in clinical OSCEs, and an alternative model which utilises rest stations for candidates is described below which would allow 14 candidates to sit in a morning (or afternoon) session.

Photo 2 for blog

This would provide 4 extra places per sitting and 16 additional places per year at minimal extra cost. Ignoring small marginal costs and using the same assumptions of filling all places and not using more than one place for any reasonable adjustments, the cost of delivery per place could be significantly lower.

I will let you the reader work out the potentially unacceptable aspects of the particular model described above. I would like to mobilise the considerable intellect of the Faculty membership. Please send to Educ@fph.org.uk a clearly specified timetable for a model that increases the number of candidates who can be examined in a session from the current 12 with the same number of examiners AND provides an ideally identical but at least equivalent experience for all candidates. To enable this model to be considered by the next Education Committee please submit any proposals before the end of October.

I have described the challenge as a prize well worth having, and I will personally endow a small prize for anyone who submits a model that meets these criteria that is implemented by the Faculty.

Written by Brendan Mason FFPH, Chair of the FPH Education Committee

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As part of FPH’s Public Health Funding campaign, I’ve been leading a Health Foundation funded programme of work examining the role that the NHS plays in prevention now and exploring where the NHS could add the most value in system wide prevention activity in the future. Our project began in July and I’m really pleased to now share with you some of our findings so far.

In order to better understand the current state of play, FPH commissioned an evidence review to examine three key questions:

  • What are the main types of prevention work researched in various NHS settings?
  • What are the benefits of prevention programmes in the NHS?
  • What helps and hinders prevention in the NHS?

For any public health professional or policy-maker, this review is a must-read, neatly summarising on-going activity from over 400 studies, sharing learning about the incredible variety of NHS-led prevention work occurring in communities, primary care, and hospitals and distilling organisational and system wide enablers to the delivery of effective prevention work.

It’s great to see such a wide range of effective, NHS-led and delivered prevention work. I won’t go into all of the findings in the review in this blog because there are simply too many, but I thought I would share with you some of the key themes that resonated with me:

1. Prevention is better than cure. The National Institute for Health and Care Excellence (NICE) use cost-effectiveness to determine which medical treatments to fund. A large amount of preventative interventions meet these thresholds but we do not necessarily invest in them. If we want the NHS to promote wellbeing rather than fire-fighting against ill-health we need to invest in prevention.

2. Prevention only works when you have staff and public buy-in. Training staff in prevention is effective so why not make it part of every healthcare professional’s education? I wish I had given prevention advice to every patient I saw with the same emphasis I placed on ensuring I knew about their drug allergies. Programmes such as Making Every Contact Count are a step toward this and neatly avoid becoming tick-box exercises by getting staff buy-in. Without us educating frontline staff and the general public about the need for preventative action and personalising the advice given to make it relevant to them, our well-meaning advice has been found to fall on deaf ears. It must also be noted that many current preventative approaches are not involving hard to reach groups, which contributes to a widening of health inequalities. This shows we still have some way to go to make prevention in NHS settings work for everyone and also raises some questions about our understanding of ‘what works.’ Does an intervention ‘work’ if it contributes to health inequalities?

3. There is a lack of mental health prevention activity. There is a huge opportunity to really make a difference if we can invest in mental health prevention. 1 in 5 people have suffered from anxiety or depression in the past year so giving people the tools they need to deal with these conditions may increase their resilience and wellbeing. As we saw from the response to my last blog, mental health professionals including the previous National Medical Director for Mental Health want to make prevention a priority, but they need resources to make this a reality.

4. The NHS should concentrate on strengthening community partnerships and integrating prevention into core services. Recurring barriers to successful prevention interventions were: a lack of integration into core services, lack of infrastructure to support prevention and cross-sector communication. The NHS actually does a lot of community preventative work including NHS Health Checks and the NHS Diabetes Prevention Programme. Though health professional opinion may be split on these programmes I would argue that it is how best to implement these programmes and make them successful that we should be working on. My own work in evaluating NHS Health Checks for Hertfordshire County Council highlighted that the NHS Health Check is great at diagnosing patients but not so good at delivering lifestyle changes and the published evidence corroborates this. We need to work with healthcare leaders to get staff and organisational buy-in to delivering such interventions in an integrated and collaborative way.

To read the full review click here.

We have recently shared this review with healthcare leaders who attended our 8 October workshop on the role of the NHS in prevention at the Health Foundation and we discussed their thoughts on our findings. We are now writing up a discussion paper from that workshop and look forward to sharing it with you soon.

Please stay tuned to the FPH blog and follow @FPH on Twitter to hear more about our progress. If you wish to comment, contribute, or donate to the campaign please contact policy@fph.org.uk or visit the public health funding page of the FPH website by clicking here.

Written by Ahmed Razavi, Specialty Registrar in Public Health

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Cities across the world compete to win inward investment and employment. Could we do more to help them compete on grounds of health-enhancing environments?

P Insall at parliament

I am always impressed by the enthusiasm of public health colleagues for cross-sector partnership working, particularly in my field of work, built environment and transport. Professional bodies – including the Faculty of Public Health – form multi-sector partnerships to influence government thinking. NICE, Public Health England and other agencies work to influence non-health sector professionals who create the conditions that determine population-level behavioural choices. Individual public health professionals support their local colleagues in these fields, offering them support and advice.

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A hostile environment is also less appealing to business (photo: P. Insall)

Among these local partnerships are collaborations with major private sector employers. These demonstrate that business is aware of the benefits to be gained by, for example, more staff walking and cycling to the workplace. However, such local projects may as yet be somewhat marginal to the business, packaged as corporate social responsibility rather than part of the core focus on productivity.

At the same time, some businesses can be obstinate opponents of local authority efforts to create health-enhancing environments, such as better conditions for active travel as recommended in NICE guidance.

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Cycle commuting is growing rapidly in London: good for productivity (photo: D Williams)

An example of this problem is retail traders, who often overestimate the importance of private motorised transport in bringing custom to their businesses.

In the Austrian city of Graz, retailers overestimated the importance of car access to their businesses by almost 100%.

In Edinburgh, shoppers’ concerns were overwhelmingly about the safety and comfort of the pedestrian environment, but retailers’ number one issue was “more parking”.

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Wouldn’t you like to live here? Business leaders might feel the same way (photo: D Black)

In a Bristol study, retailers thought customers on foot and by car would each be about 40% of the total: in reality, 55% walked and only 22% drove. This kind of misperception almost guarantees that traders will lobby against their own interests, and in favour of more traffic, noise, congestion and pollution, to the detriment of public health.

So is it worth putting precious effort into cultivating a private sector which can seem to be an obstacle? I would say, yes it is. Business is much better than government, at any level, when it comes to horizon scanning, long-term planning, and ruthless decision making. In a shrinking and increasingly competitive world, factors such as Brexit and the ageing workforce mean that ‘business as usual’ is not an option for business leaders. Public health can make the case that disease prevention and health promotion should be important factors in the planning of the private sector as a whole and the individual businesses within it.

Take for example the CBI. The CBI was involved in the 2015 Active Cities Summit, launching research – from Active Living in the USA – which indicated economic advantages for cities which facilitate active lifestyles. The CBI this year went on to launch its own Health and Wellbeing Survey to “uncover what more could be done to support employees in the workplace”.

Meanwhile, the Institute of Directors has recognised “a basic business case that attention to [employee] health and wellbeing boosts productivity and engagement”, and now offers evidence and advice to its member businesses.

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The ‘feel’ of a city can influence its commercial competitiveness (photo: P Insall)

These initiatives are in themselves positive, and should offer opportunities for us to work more closely with the private sector. However, the opportunity presented by the Active Cities approach goes much wider. As I noted for the government’s Foresight study into the Future of Cities,

“Any city in any nation is already today in competition with others, for influence, brand recognition, economic activity and employment.

“If the global perception of a city is that children scoot or cycle safely to school along quiet, tree‑lined back streets – and if a CEO considering inward investment can visualise his or her children doing so – it may have a critical competitive advantage.”

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Safe, attractive routes to school, appealing to all parents (photo: Sustrans)

Can business and public health make common cause on this? Can we work to drive the creation of healthier environments where individuals can make healthy lifestyle decisions, directly assisting cities to win inward investment and businesses to maximise their productivity.

Maybe it’s time for another Summit, this time bringing together the national leaders in public health with those developing the strategies of the private sector as a whole.

My comments above relate primarily to transport, planning and public health – active travel and physical activity, air quality, climate change and the associated social issues. I hope though that they may have some relevance in other fields, including food and nutrition, alcohol and smoking.

Written by Philip Insall, Director, Insall & Coe, and Honorary member of FPH. You can follow Philip on Twitter @philipinsall.

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