Archive for December, 2018

bronte 10kOctober 2018 and I flew 10,000 miles to Sydney to start my final year of training in a different system. It requires a very different ‘winter’ wardrobe!

I’m spending eight months hosted by South Eastern Sydney Local Health District and based at the oldest working hospital in Australia. Having been here almost two months I’m getting used to a host of new acronyms and a healthcare system which includes a combination of Public Health responsibilities at commonwealth, state and district level and a bigger role for fee paying services than in the UK.

What was clear from my first day here however was not the differences but the similarities. Discussions around an ageing population and a desire to integrate care and risk-stratify the population made me feel very much at home straight away. A stereotypical image of Australia is that it is universally active and ‘healthy’ but rises in obesity, diabetes and mental health are huge challenges here, just as in the UK. In addition the impact of climate change is becoming, albeit slowly, a big issue in a country that has already seen the impacts of increasingly adverse weather events, especially droughts, heatwaves and bushfires.

The health and wellbeing of the Indigenous population, aboriginal and Torres Strait islanders, is something that shouldn’t and cannot be ignored. Prior to colonisation the Indigenous population had a 60,000 year history here but have only been counted as part of the population (via the census) for the last 50 years.

Aboriginal people can expect to live at least 10 years fewer than everyone else in Australia. Virtually all health indicators show vast inequalities between the Indigenous and non-Indigenous populations. Despite making up only 3 per cent of the general population they constitute 28 per cent of the prison population. Rates of smoking are more than two and a half times that of the rest of the population. Indigenous children are more than 10 times as likely to be removed from their families and placed into state care as non-Indigenous children. The list goes on and on.

The term ’aboriginal people’ suggests a single homogenous group. In fact, the map below illustrates how Indigenous communities see the boundaries within their land rather than the states and territories which have emerged in the last couple of hundred years. Hundreds of separate regions with separate languages, customs and traditions.

Australia map image.png

During my placement in Sydney I’ll be based within the Eora nation and on the lands of the Gadigal people.

I’m placed with SESLHD (South East Sydney Local Health District). SESLHD is an organisation responsible for the health of almost a million people. It covers urban areas in some of Australia’s most prestigious neighbourhoods as well as areas of high deprivation and has the world’s second oldest national park within its boundaries. SESLHD covers nine hospitals with commissioning and management responsibilities for a range of community services and everything from pre-birth to palliative care. I guess Clinical Commissioning Groups are the closest ‘fit’ with local health districts.

I’ll be leading on a couple of work areas. Firstly, the development of an Environmental Sustainability Plan for SESLHD. Secondly, I’ll be investigating patient pathways looking for opportunities to reduce variation and integrate services across a number of areas, including paediatrics and Child and Adolescent Mental Health Services.

I’ve also been fortunate to be awarded a scholarship with the Deeble Institute, a research unit within the Australian Healthcare and Hospitals Association (AHHA), and I’ll be working with them to produce an evidence review around the role of accreditation in healthcare. This has already involved spending time in the national Capital, Canberra. I was part of a delegation from the AHHA who met with the Minister and Shadow Minister for Health in Parliament.

Finally a word on the Public Health training here. I’m discovering there are both similarities and differences with training in the UK. The Australasian Faculty of Public Health Medicine is responsible for a three-year public health training scheme for medics. Some of the states also run additional Public Health Officer training programmes for medical and non-medical staff – the largest of which is here in New South Wales. As part of my placement I’m spending time with trainees from both schemes and attending some of their training – and they’re social events of course!

Trainee xmas night out

So in summary, so far it is a great placement with great people and lots to learn. It doesn’t feel like Christmas as I write this in my shorts looking at the beach but the conversations about the Coca Cola truck confirm that it’s that time of the year and that some things in Public Health are universal!

I’ll be writing more about my time in Australia towards the end of my placement. I’m keen to reflect on what lessons I can bring back to the UK and consider what new opportunities there could be for registrars across the commonwealth in a post-Brexit world. In the meantime, I’ll be making an effort to tweet more about my time in Sydney so please feel free to follow me on Twitter and ask any questions @RyanSwiers.

Written by Ryan Swiers, Specialty Registrar in Public Health

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Today we’ve published FPH’s first major contribution to the national discussion about the role of the NHS in prevention.

Our discussion paper – the first of three we’ll be publishing – reflects many months of thinking and engagement with key NHS and public health stakeholders and the conclusions of an evidence review of prevention initiatives in the NHS.

It is also the first major ‘output’ from our Role of the NHS in Prevention project, which has been funded via an award from the Health Foundation.

We explore three main themes in the discussion paper:

1. What does the evidence tell us about what works?

We’ve discovered that there is lots of good evidence about what helps or hinders prevention in the NHS. But there are still far too many evidence gaps and there’s a very long way to go to make the evidence we do have as useful as possible for NHS leaders, local commissioners and providers. In the meantime they are all having to make ‘best guess’ decisions about which NHS prevention initiatives are likely to provide the most ‘bang for buck’ in their local area.

2. What are the different roles the NHS plays in support of the prevention agenda?

We heard that although NHS organisations are doing a lot of prevention, there is a sense that the NHS responsibility for and capacity to do prevention is poorly defined and poorly understood. This confusion can sometimes impact on service delivery. Based on our evidence-gathering about what prevention in the NHS currently looks like, we’ve come up with five descriptors that we think do a good job of summarising distinct NHS prevention activity:

i. Leader – e.g. commissioning services, providing governance and management, setting the national agenda, role-modelling.

ii. Partner – e.g. providing services, hosting services, working in collaboration to deliver services with local authority, statutory, or other voluntary sector entities.

iii. Employer – e.g. initiatives aimed at improving NHS staff health and wellbeing; NHS as a community employer and ‘anchor institution.’

iv. Advocate – e.g. lobbying governments on public health agenda, lobbying for prevention within individual institutions.

v. Researcher – e.g. funder and driver of new research.

It’s important to stress that we know these categories often overlap and are imperfect descriptors of a diverse range of activity. We’ll be looking to refine these as the project continues.

3. Where should the NHS focus its prevention efforts, now and in the future? In October FPH held our first NHS prevention stakeholder workshop. Over 40 healthcare leaders from across the UK came together to share their knowledge and ideas. Our discussion document sets out a shortlist of 11 prevention interventions that they said should be the focus of the NHS’s prevention efforts. But the majority of experts agreed that a collection of individual interventions alone will not deliver the kind of change we need to support the long-term sustainability of the NHS. A systems approach was identified as a crucial way of achieving change at a population level. We think the NHS should focus some of its effort towards this longer-term goal without losing sight of the fact that delivering more cost-effective prevention interventions could still be very impactful now if implemented in a place-based way and integrated into regular services.

As we set out the themes we will be exploring in more detail in future discussion papers, what’s already clear is that ill-health prevention is a significantly under-exploited way for the NHS to keep people healthy and better manage demand on services. The forthcoming NHS England long-term plan and the UK Government’s prevention green paper offer ‘once-in-a-generation’ opportunities to further promote prevention and make the step-changes we need to integrate prevention into the day-job of every healthcare professional. We hope these opportunities will be grabbed with both hands.

The whole point of a discussion document is to encourage more people to build on the ideas we’ve set out, to challenge them (please be nice!), and to inspire new thinking. We would be very interested to hear your comments and answers to the various questions we pose. You can do this in three ways:

  • By tweeting us @FPH
  • By emailing us via policy@fph.org.uk
  • If you’re an FPH member, by joining our Public Health Funding Campaign ‘sounding board’ and getting involved in the further development of our thinking. Email policy@fph.org.uk to find out more

The final thing to say is a huge thank you to everyone who has contributed to the Public Health Funding project so far. We are extremely grateful for all your help and please do continue to get involved. Click here to read the discussion paper. 

Written by Ahmed Razavi, Specialty Registrar in Public Health and member of FPH’s Public Health Funding Project Group, and Lisa Plotkin, Senior Policy Officer and FPH’s Public Health Funding Project Group Lead.

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The Nanny State Debate

I first read George Orwell’s 1984 when I was fifteen and it terrified me. Never had I experienced such an acute realisation of the importance of human freedoms and civil rights. This never left me during my first career working for ‘the state’ as a psychiatric nurse within the National Health Service, and it has become ever more salient during my current career working for ‘the state’ in public health.

Public health is first and foremost a belief that a better world is available to us through planning, organising, collaboration and action. A world with less disease, fewer premature deaths, and greater equity in the achievement of human flourishing and wellbeing.

It goes without saying that all potential actions can provoke debate and the voicing of concerns. Such concerns can be sincere or cynical, and it is helpful to be able to differentiate them in order to inform one’s best response.

This is where FPH’s Special Interest Group (SIG) on public health ethics comes into its own. Having secured the invaluable involvement of professional philosophers, ethicists and legal scholars, the SIG works to strengthen our understanding of relevant issues in political philosophy, ethics and law, and how to deploy these in our everyday practice. Leading the case for change requires engagement with such issues, as much as it requires engagement with the empirical epidemiological and healthcare evidence base.

Of particular relevance here is the recent report on the Nanny State Debate authored by Professor John Coggon Hon MFPH, Professor of Law at the University of Bristol. This resource, in which Professor Coggon generously makes the breadth and depth of his scholarship accessible to the public health workforce, provides the key facts one needs to know to be able to classify voiced concerns of ‘nanny statism’ and respond appropriately.

People can have heartfelt concerns about human autonomy and proposed restrictions on freedom of choice. I relate to this in light of my early experience of reading Orwell. Professor Coggon’s report reassures me that it is entirely appropriate to recognise and acknowledges these concerns. Dialogue is worthwhile, making use of empirical evidence to set out the issues and the benefits of action, while other relevant values can be introduced for consideration alongside freedom, such as fairness, equality, and solidarity. In this way, progress can be made.

Alternatively, vested interests whether financial or power-based or both, can cynically seek to prevent action to protect or improve population health. I suspect we will each have had our own experience of this in one form or another. Professor Coggon clarifies how claims of ‘nanny statism’ can be deployed to shut down debate and block action. Direct attempts to engage and persuade, through evidence and appeals to justice, are unlikely to be effective. As public health professionals we need to know how to craft public responses to constructively maintain debate and momentum for action.

In summary, I found The Nanny State Debate to be concise but hugely thought-provoking, and a valuable addition to my public health ‘toolkit’.

At a time of ecological crisis, growing inequalities, and stalling life expectancy we need evidence-based and values-based planning, organising, collaboration and action more than ever before. As a practitioner on the public health front line may I commend Professor Coggon’s report to you, and urge you to read it and put it in to action.

Written by Christopher Littlejohn FFPH, Deputy Director of Public Health, NHS Grampian. 

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Jonathan ShepherdSince its foundation, the Faculty of Public Health (FPH) and the organisations from which it was built have advanced public health standards, which is done on the basis of continuously evolving knowledge of what constitutes best practice and policy. In turn, this knowledge is based on the best quantitative and qualitative evidence available. The nature of this evidence has also evolved. Controlled, and, where feasible, randomised trials are now the source of a great deal of the best evidence about what works, what doesn’t and what represents good value for money. The health of the public now relies on such evidence.

Perhaps the main role of FPH and of its parent Royal Colleges with regard to evidence is to make sure it is infused into the professional lives of their members and fellows and is applied – through the curriculum, through career advancing membership and fellowship examinations and assessments, through courses, training standards and wider CPD, through journals and policy statements, and through their networks of advisors. This function is often called evidence mobilisation.

Importantly, FPH also provides powerful incentives to excel – prestigious and eponymous prizes for example. These are often awarded for excellence in evaluation and development and then, through personal example, for pioneering and promoting better practice and policy based on this.

FPH and RCP (The Royal Colleges of Physicians) also provide welcoming professional homes – attractive environments in which practitioners and policy makers engage with the latest evidence and guidance and decide how it might inform and change their practice.

But this Royal College model of continuous improvement was not adopted by some other professions until very recently. It seems astonishing that until 2014 there was no such institution for the police, and until 2016, no professional body for teachers in primary and secondary education.

Since evidence has come a long way in the last few decades across all of these policy areas, it seemed to me that a declaration on evidence, signed by the relevant professional bodies, would strengthen a culture of evidence-informed policy and practice in these institutions and in the professional lives of their members and fellows.

Declaration of evidence

As an honorary fellow of FPH and a member of FPH’s Academic & Research Committee, I drafted this declaration and then took it through the boards of the Academy of Medical Royal Colleges, the Chartered College of Teaching and the College of Policing. It was signed by leaders of all the Royal Colleges and police and teaching institutions at the Royal Society on 7 November 2017. This event was facilitated by the Alliance for Useful Evidence and chaired by the former Cabinet Secretary, Lord O’Donnell. The Faculty president, Professor John Middleton, signed for FPH.

Blog 1

The signing ceremony at the Royal Society*

This declaration signals FPH expectations of all its members and fellows with regard to evidence and also signals its commitment to support high quality evaluation.

At the signing event at the Royal Society I introduced the declaration and commented that:

This is a unique meeting of leaders of professional bodies in healthcare, teaching and policing. Teachers, police officers, doctors and dentists make up a sizable proportion of the UK workforce. The influence of the institutions represented here extends to more than one million professionals across the UK and more widely. This event is testament to the great importance of evidence for our professions and for the public we all serve.

*The people featured in the photo are:

Front row, left to right, Chief Constable Ian Hopkins, director, College of Policing; Professor Carrie MacEwen, chair of the Academy of Medical Royal Colleges; Dame Alison Peacock, chief executive, Chartered College of Teaching. Back row, left to right, Lord O’Donnell, former Cabinet Secretary; Professor Jonathan Shepherd, declaration author; Jonathan Breckon, director, Alliance for Useful Evidence.

Written by Jonathan Shepherd, professor of oral and maxillofacial surgery at Cardiff University. Jonathan is a fellow of the Royal College of Surgeons of England and the Academy of Medical Sciences, and is an honorary fellow of the Royal College of Psychiatrists and the Royal College of Emergency Medicine. He is a member of the Home Office Science Advisory Council and the What Works Council at the UK Cabinet Office.

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The Public Health Dashboard is an online, easy to use tool providing information at your fingertips on a number of indicators related to local activity to improve the public’s health and wellbeing. You can learn more about the tool, the data it presents, and how to use it here.

Tools like this one are aimed at local decision-makers, such as senior council officers, to help inform their investment decisions. This will be especially useful when, at some future date, the public health grant fence is removed. At the moment, the tool includes the following local authority service areas:

  • Best start in life
  • Child obesity
  • Drug treatment
  • Alcohol treatment
  • NHS Health Checks
  • Sexual and reproductive health
  • Tobacco control
  • Air quality (interim indicator)

Based on feedback, PHE (Public Health England) and the Faculty of Public Health (FPH) have embarked on a partnership to consider the inclusion of wider determinants of health indicators in the tool and ensure that the voice of the public health workforce is reflected in the final outcome. Our members believe that if this tool is really going to help them make the case in their local authority for more investment for the interventions or services that keep us healthy and well, then indicators that speak to places, sustainability, good jobs, and community cohesion need to be included alongside the mandated services.

However, there are potentially hundreds of ‘wider determinants of health’ (WDOH) indicators that could be included in the tool. To come up with a manageable list of indicators to consider in more detail, we surveyed FPH members about influence and impact. Here is a summary of what they told us:

The Top 5 indicators that councils can influence

  • Active transport
  • Number of premises licensed to sell alcohol per square kilometre
  • Density of fast food outlets within 400 metres of schools
  • Density of fast food outlets
  • Access to parks and recreation spaces

The Top 5 indicators that impact health and wellbeing of local residents

  • Overcrowded households
  • Social isolation in adult social care users
  • Fuel poverty
  • Statutory homelessness
  • Active transport

The survey findings provided us with a wealth of information about influence, impact, and future priorities for our members in terms of the work that they are currently doing locally and also what they think will become more important over the next 2-3 years.

We then used our survey findings to inform two workshops held in London and Birmingham in early November. The workshops were attended by FPH members working in local authorities. Over the course of two afternoons, we had lively and interesting debates about the indicators and how a simple tool like the dashboard could best represent a complex area, such as the wider determinants.

The PHE team is still considering the next steps in terms of how – or indeed if – to incorporate the WDOH indicators into the tool. We hope to use the findings from this work to do a larger project, examining how our members and others working public health can better influence spending in their local authority to tackle the wider determinants of health.

If you would like to get involved in our work or learn more about this project, please email policy@fph.org.uk or click here.

Written by Lisa Plotkin, Senior Policy Officer, FPH

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A thread that runs through the entire Public Health Funding Campaign is the need to demonstrate the value of public health and the vital work public health professionals do. As Steve Brine, Minister for Public Health and Primary Care, said earlier this year:

The competition for resources isn’t getting less fierce. We all need to get better and smarter at making the case for our share of resources.

As well as gathering and generating the evidence we need to make the case for investing in public health across our three policy ‘asks’, we wanted to find a way to visually bring it to life as well.

As you’ll know from this blog, it’s challenging to find photos that communicate what public health is and the diverse nature of the work our members do, so we decided to change that.

We launched a photo competition to challenge our members and wider public health community to take a photo that illustrates what ‘public health looks like’ through their eyes. The aim was to celebrate the breadth, diversity and importance of public health in the UK and around the world, and we were blown away by the entries.

From the moment we launched the competition in mid-July, we were overwhelmed by the positive responses we received, so it’s important to take this opportunity to thank absolutely everyone who helped us make it such a success. When we closed the competition in October we’d received over 200 entries, including some spectacular images covering a whole range of public health activity from community outreach programmes combating loneliness to immunisation clinics in the Middle East. A large chunk of the entries we received were from non-members, indicating how many people are engaged in FPH and the valuable work our members and other public health professionals do.

The story is not over yet though. Our judging panel, made up of both public health and photography experts, met on 13 November to narrow the impressive array of entries down to a final shortlist. Before beginning the judging, the panel agreed that they wanted each of the selected photos to tell a public health story in its own right and be visually arresting as well as technically proficient. They also wanted the final shortlist as a collection to showcase a broad and diverse range of public health activity. In the end the standard was so high that, instead of 20 photos, this shortlist ended up including almost 30.

Vote for your favourites!

It’s now down to you, our members, to decide on the ten photos that will be displayed at FPH’s first ever photography exhibition. The winning photos will also have a permanent home on our website, and will be used as a travelling exhibition, displayed at key events throughout the year.

Please get involved by taking a look at the shortlisted photos, then voting for your five favourites via this link.

We are so excited to hear your views on the final photos, which we can all use to celebrate public health as we see it and strengthen the case for increased funding of our vital public health services. We hope they make you proud to work in public health because they make all of us at FPH proud to represent you.

To cast your vote, click here!

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, like Rachel, you’re a Specialty Registrar and want to get policy & comms experience by joining our Registrar Project Scheme, email policy@fph.org.uk to find out how you can apply.

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As part of FPH’s Public Health Funding campaign, we are undertaking a project examining the role that NHS organisations play in prevention.

We have received an award from the Health Foundation to carry forward a varied work programme over the course of 9 months, involving our members from across the UK and other key partner organisations. The project aims to:

  • Build a better understanding of how the NHS currently delivers prevention
  • Understand what ‘good’ prevention in the NHS looks like
  • Explore the barriers and enablers for NHS organisations seeking to take a more preventive approach
  • Determine initial priorities for increased investment or focus – including interventions, approaches, and workforce needs

As part of our work so far, we have commissioned an evidence review exploring prevention in the NHS, which looks at 3 main topics:

  1. What are the main types of prevention work researched in various NHS settings?
  2. What are the benefits of prevention programmes in the NHS?
  3. What helps and hinders prevention in the NHS?

The review is a unique and fantastic overview of prevention approaches in different NHS settings. It looks at impact, what works and what doesn’t, and what might improve current approaches if done well. The review highlights the importance of a systems approach, and engaging with both staff and the public. For a summary of some of the main takeaways please have a read of this blog or have a read of the review itself.

We also held a stakeholder workshop in October gathering expert opinions on prevention in the NHS, which we used to inform part of FPH’s submission to the NHS long term plan consultation. Attendees at the workshop included representatives from NHS England, Public Health England, Cancer Research UK, and the Royal College of Physicians.

A key takeaway from the day was that this is a complex topic, but colleagues across the health field are committed to supporting the NHS to do more, better, and system-wide prevention. We will soon be publishing our first in a series of discussion papers, summarising our learning so far and discussing some of the tensions we still need to reconcile. We’ll also be posing some key questions around the evidence base and priority areas for action that we will need our members to help us answer. We then plan on hosting two more workshops in the Spring to continue building our evidence-base and drawing together expert advice and consensus.

This is a really exciting piece of work and has been expertly supported by the wider FPH team and our Public Health Funding Advisory Board, who graciously give up their time to contribute. Please stay tuned to the FPH blog and follow FPH on Twitter to hear more about the progress of the campaign. 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 and member of FPH’s Public Health Funding Project Group

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