Better Health For All

The third edition of the Public Health Film Festival recently took place in Oxford and was host to award-winning films from the International Public Health Film Competition supported by the Faculty of Public Health, Public Health England, The Oxford Research Centre for the Humanities and the Wellcome Trust Centre for Ethics and Humanities.

The public health film competition was more popular than ever, with over 550 films from 72 countries submitted for consideration. Members of the Public Health Film Society scored the films using a list of ten criteria previously published in the Journal of Public Health and a shortlist of 15 films was put forward for consideration by a committee of experts from the world of film and public health, including Professor John Middleton from the Faculty.

The judges’ award for the best health film this year was shared jointly by Budh (Awakening) a powerful film and directorial debut of Indian Director, Prashant Ingole, that tells the story of three women from different corners of India and their struggles against barriers that bind women in this vast country; and Buddy Joe, an entertaining animation from French director, Julien David that imagines how an elderly artists suffering from Parkinson’s Disease tells his step-son about his disease.

The highly commended award was given to Sarah Holloway for her documentary film, Lucy: Breaking the Silence which movingly recalls the story Lucy Rayner who took her own life, the effect on her family and the issue of mental health among young people in the UK.

The film festival offered audiences the opportunity to see most of these films for the first time in UK, to talk with film-makers about their motivations for making them and share the journey they have taken to make and showcase their films.

In addition this year, The Public Health Film Society (PHFS) in collaboration with the Wellcome Centre for Ethics and Humanities introduced an award for the health film that was most well received by the audience at the festival. This inaugural audience award was won by Lucy: Breaking the Silence and was presented by Professor John Middleton to Sarah Holloway, the film’s director.

On behalf of the FPH Public Health Film Special Interest Group (SIG), I can say that we are delighted with the success of the International Public Health Film Competition this year. It clearly shows that there is a high level of interest in health films among the artistic community and a global pool of talent working on health films and we are honoured to provide these films-makers with a platform to showcase their award winning work and share their experience.

Written by Dr Uy Hoang, Chair of the FPH Public Health Film SIG and President of the Public Health Film Society. 

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The government has announced a consultation on its future proposals for local government funding and our analysis shows that these proposals would take more money from poorer local authorities and give it to richer ones – widening social and health inequalities. If we are going to address the huge inequalities this country faces we must allocate a greater share of local government funding to areas that have been economically ‘left behind’.

The proposals, currently out to consultation until 21 February 2019, are for new funding formulae that will be used to assess how much funding each local authority needs to provide essential services. Under the proposals a new “foundation” formula will determine the share of funding that each council receives for services to improve the environment in which people live (e.g. parks) , housing and preventing homelessness, leisure facilities (e.g. swimming pools, libraries), culture (e.g. museums) and planning as well as community and economic development.

Extensive research has shown that these services have a major impact on people’s health and that greater investment in these is needed in more disadvantaged communities who have poorer health, if we are to address the huge and widening health divide that blights this country. These foundation services – largely provided by district councils, are the foundation for good health. Indeed, the current formula, adjusts for levels of socioeconomic deprivation allocating 20% more resources per head to disadvantaged local authorities to provide these services. But the government’s new proposal is that differences in need should not be taken into account in the future. Rather they propose that each council in England should receive the same funding per head for these foundation services, regardless of differences in need.

In England there is a long history of allocating local government and NHS resources to local areas based on an objective assessment of their needs. This has led to more resources for these services going to the poorest areas with the greatest needs, which we have shown has resulted in a narrower gap in health between these areas and the rest of the country than would otherwise be the case. The government’s proposals would bring this to an end for these council services. If implemented today, figure 1 shows that the new allocation formula would lead to the most deprived 20% (quintile) of councils losing £35 per head per year – a total of 390 million per year, whilst the most affluent 20% of councils would gain £24 per head – a total of 260 million per year. (Click here for an interactive map showing the impact for each council.)

Assessing differences in needs between areas is complicated, and the consultation document is highly technical, the serious implications of these proposals therefore, could easily have been missed. The standard practice used for assessing differences in need is to investigate the factors that are associated with differences in historical spending per capita between places and to use these as a proxy for need. One of the key predictors of need is the level of socioeconomic deprivation in an area, an indicator which is well developed and established in England for use in resource allocation and public health needs assessment.

But the consultation erroneously justifies not including socioeconomic deprivation as a measure of need for these foundation services by claiming that it only explains 4% of the variation in historical spend on these services. This is based on a flawed analysis that investigates predictors of total spend, rather than per capita spend, as would be standard practice. In fact, using the correct analysis, socioeconomic deprivation is a very strong determinant of variation in historical per head spend on foundation services. Using 2016 data – we show that social and economic deprivation explains 16% of differences in spending per head on foundation services. Even this is an underestimate of how much deprivation is a driver of need for these services, as the budget has been severely cut during recent years due to the government’s austerity programme. These cuts have been far more severe in deprived areas than in more affluent areas, leading to significant unmet needs in the most deprived areas. Figure 2 shows that since 2009 the poorest councils have lost on average £160 per head for these foundation services, whilst the richest councils have lost £50 per head.

A better estimate of the extent that deprivation predicts need for foundation services would be to use data from 2009 before these cuts were applied. On this basis deprivation explains 40% of the differences in spend per head between councils of these foundation services. In other words we estimate that deprivation is a 10 fold greater driver of need for these foundation services than has been estimated in the government’s consultation document. Figure 2 (below) shows that applying a formula that took into account this difference in need would allocate an additional £28 per head to the most deprived areas and a reduction of £24 per head for the most affluent 20% of local authorities.

Changes to the way public funds are allocated to the NHS and council areas have consequences for people’s quality and length of life. The new NHS long-term plan has a focus on prevention and addressing health inequalities that is difficult to reconcile with a council funding allocation proposal that will lead to poorer health and bigger inequalities.

Following the cuts in funding to councils in recent years – for the first time on record we are seeing life expectancy declining and infant mortality increasing in the poorest areas, widening health inequalities. To us, as public health experts, these are seriously concerning trends suggestive of something going very wrong with the current system of resource allocation. These trends have reversed progress that had been made to decrease inequalities between 2000 and 2010.

Implementing the government’s new proposals would further fuel these adverse trends, ending the tradition of allocating resources to areas according to need and replacing it with a new, unjust, norm. Even if the overall funding envelope for these services increased in the future, the proposals would mean that poorer councils received a diminishing share of these funds. If further cuts were implemented – it would mean that these cuts would hit poorer councils harder. In a country that is divided, with widening inequalities, these proposals would further cast adrift the health and life chances of people in those areas, who already feel they have been abandoned by government. It’s time to take action on inequality, by ensuring fair funding for local government, increasing investment in the communities that have the greatest needs.

Written by Ben Barr, Senior Clinical Lecturer at University of Liverpool, Professor David Taylor-Robinson, University of Liverpool and Professor Dame Margaret Whitehead, University of Liverpool.

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How can we apply the principles of human rights to our work in Public Health? While many of us have some training in medical or bio ethics, few of us have more than a superficial understanding of human rights. In advocacy work around migration I have often found myself quoting from various documents such as invoking the ‘right to the highest attainable standard of health’ from the Committee on Economic, Social and Cultural Rights but rarely have I fully understood the context. Therefore when the opportunity came to attend a seminar in Salzburg on ‘Human Rights in Patient Care’, I jumped at the opportunity. Expanding on the concept of ‘Patient Rights’, the seminar took a broader viewpoint to capture all stakeholders in the delivery of care. 

Alongside doctors and lawyers from such places as Sudan, Vietnam and Slovakia I spent a week studying international human rights law and practice, gaining a better overview of these tools and frameworks. A highlight was meeting the UN Special Rapporteur on the Right to Care, Dainius Pūrus, who gave us his perspective on the major global issues facing health care today. These ranged from the lack of access to services for vulnerable groups, to the overuse of interventions in ever more settings. 

While a week may not be long enough to become an expert in human rights, I was left with an appreciation of the landscape. However in order to ensure that this knowledge could be easily called upon, the course organisers and many of the attendees have been working on developing ‘practitioner guides’ for both doctors and lawyers. These guides, give an overview of the laws, alongside practical examples of their application and I highly recommend anyone interested in framing health issues around human rights to explore them. The guides are country specific but start with the international frameworks and are therefore relevant globally.  Sadly there is no specific guide for the UK, but developing this could be a project for a small team. In fact considering such a process was an exercise at the seminar and there is much support available. 

Human rights should be an essential consideration in health care delivery at all levels, not least public health. Indeed many of our approaches are strongly aligned with the human rights agenda. Of concern in my work is the treatment of undocumented migrants in the NHS, where many are denied or deterred from accessing essential treatment, with concerning ethical and public health consequences. Better knowledge of human rights law gives us another string to our bow in order to better advocate for a more equitable, rights based approach to care.   

Robert Verrecchia is a London-based, public health registrar with an interest in international public health and migration and health. He is currently working with the FPH on their 5 year strategy and on migration, health and ethics. He also works with Chatham House, Public Health England’s Global Health Division and co-chairs the Médecins Sans Frontières UK Take Action Group. You can follow Robert on Twitter @Rob_Verrecchia.

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This is the second in a two-part blog that lays out our thoughts on the recently-published #NHSLongTermPlan, and where the NHS could focus its prevention efforts. If you haven’t read the first part yet, click here to read it.

So to the assessment of how well the NHS Long Term Plan measures up against the latter six of 11 priorities. (The first five priorities were discussed here.) Like many assessments in blogs it is subjective (sorry) so please do let me know your own thoughts via policy@fph.org.uk.

6. NHS staff health and wellbeing

While noting that the NHS recently published the NHS Health and Wellbeing Framework, the Plan goes further by committing to “make the NHS a consistently great place to work” including the redoubling of efforts to address discrimination, violence, bullying and harassment. However, much of the detail is still to be set out in a workforce implementation plan to be published “later in 2019” with a new Chief People Officer leading the work. We hope the implementation plan not only talks about how it will improve the health and wellbeing of NHS staff but about how those 1.4 million people can model and champion healthy behaviours within their local communities.

Verdict: wait and see what the implementation plan contains.

7. Mental health and wellbeing

The Plan makes a renewed commitment that mental health services will grow faster than the overall NHS budget, with funding for children and young people’s mental health services growing faster still. This investment will enable further service expansion and faster access to community and crisis mental health services for both adults and particularly children and young people. We welcome the commitment for NHS-funded Mental Health Support Teams in schools and colleges but there’s still much more to do to encourage better mental health and wellbeing at a population level.

Verdict: clear and very welcome commitment to improving mental health services but more to do on the public mental health side.

8. Smoking

The Plan makes clear that smoking still accounts for more years of life lost than any other modifiable risk factor. It commits the NHS to ‘a significant new contribution’ to making England a smoke-free society with new support targeted at in-patients who smoke, expectant mothers, and their partners, who smoke and smokers using specialist mental health services or learning disability services. The change in tone in how the NHS should treat people who smoke is also welcome. Smoking isn’t a lifestyle choice. It is a dangerous addiction that not only kills but significantly impacts on the health and wellbeing of friends, family, colleagues and neighbours. Importantly, the Plan also states that funding and availability of smoking cessation services (and drug and alcohol services, sexual health, and early years support for children) in local government will directly affect demand for NHS services. That’s a pretty clear, if diplomatic, way of saying to the Treasury that the NHS would like to see more money going into local government public health services in the Spending Review.

Verdict: well done NHS!

9. Alcohol

The Plan identifies alcohol as a key priority for its NHS prevention programme and commits to ensuring that, over the next five years, those hospitals with the highest rates of alcohol dependence-related admissions will be supported to fully establish Alcohol Care Teams. As outlined above, the Plan also makes the case – in diplomatic tones – for more funding for alcohol services in local government. One of the key questions is whether the NHS needs to play a bigger role in encouraging behavioural change across the whole patient population, across the national population, and be more vocal in calling for national policy reform. For example, should the Plan have mentioned MUP?

Verdict: a focus on the ‘crisis’ end of alcohol treatment but more to do when it comes to establishing healthier relationships with alcohol amongst the wider patient and national populations.

10. Early years

The Plan commits the NHS to playing a crucial role in improving the health of children and young people while making clear that better healthcare can never compensate for the health impact of wider social and economic influences on children’s and young people’s health. There are a number of ‘public health’ commitments including the roll out and expansion of the Saving Babies Lives Care Bundle (SBLCB), reducing smoking rates during pregnancy, better access to mental health services, improving breast-feeding rates and childhood immunisation. But having highlighted the wide range of social and economic influences on children’s health, it is questionable whether the Plan does enough to integrate the NHS effort with these wider forces or to recognise the urgency and scale of the health challenge.

One of the more controversial aspects of the Plan was the announcement that the NHS would consider whether there is a stronger role for the NHS in commissioning health visitors and school nurses. The response from the public health community has been pretty universal. The issue is not about the quality of local government commissioning but simply the lack of funding.

Verdict: positive but more needed and the commissioning proposal sent the wrong signal, no doubt unintentionally, to the public health community.

11. Health promotion

The Plan highlights that every 24 hours the NHS comes into contact with over a million people at teachable moments in their lives. It sets out practical action to do more to use these contacts as positive opportunities to help people improve their health. For example, one of the ways set out in the Plan is a commitment to ensure staff on the frontline feel equipped to talk to patients about nutrition and achieving a healthy weight.

The commitment to do more to support secondary prevention is very welcome. The diplomatic call for more funding for the local authority public health grant as part of the Spending Review is also greatly appreciated. The NHS desire to draw a distinction between the role of the NHS vs the government, NHS England vs Public Health England, and the NHS vs local authorities is also completely understandable.

However, the scale of the prevention challenge, and the importance of the NHS as an ‘anchor institution’, means that the NHS can’t not play a clear leadership role in promoting and championing good mental and physical health in local communities and at national level.  The Plan’s commitment to work in partnership with the Health Foundation to identify and encourage the take-up of good practice in local areas across the country is welcome but the scope of the ambition feels limited (at least at this stage) for a ten-year, transformative plan.

A month after the Plan was launched, NHS England has been willing to make the case in public for greater social media regulation to protect the public’s health.  In some ways this makes it even more curious that it did not use the opportunity of the Plan itself to actively champion reform of key public health policies – particularly those policies directly related to the key risk factors identified in the Global Burden of Disease study.

Verdict: very welcome commitments but the NHS needs to play an even more significant role in championing action to keep people happy and healthy.

Verdict overall: the NHS Long Term Plan puts tackling health inequalities at its heart and for that alone it needs to be loudly applauded. But alongside this landmark commitment there are a host of other very positive and welcome proposals. What’s needed now is an even greater shared commitment from the NHS and the public health community to collaborate and co-create the specifics of how to narrow health inequalities and shift the NHS’s balance still further from curing illness to preventing it. If the Long Term Plan ends up being the ‘NHS’s plan’ and the forthcoming Prevention Green Paper becomes the ‘local authorities’ plan’ then we may well look back at 2019 as an opportunity missed.

If you haven’t already, please read the first part of my blog by clicking here and also consider sharing your thoughts via email: policy@fph.org.uk.

Written by Gus Baldwin, Director of Policy and Communications, FPH. You can follow Gus on Twitter @Gus_Baldwin.

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This is the first in a two-part blog that lays out our thoughts on the recently-published #NHSLongTermPlan, and where the NHS could focus its prevention efforts. The second part can be read here.

I thought it might be interesting to assess the recently-published NHS Long Term Plan against the shortlist of prevention priorities FPH set out in our December Prevention in the NHS discussion paper.

First some quick background. In October last year, FPH invited more than 40 senior NHS and public health leaders to a policy workshop to discuss where they thought the NHS should focus its prevention efforts.

One of the most challenging things we did was to co-create a ‘long list’ of prevention priorities. We then encouraged workshop attendees to vote for eight of these priorities – eight and eight only.

From a longlist of around 30 ideas, the group collectively identified 11 key priorities.

While the process had its flaws, the shortlist of priorities produced from this ‘hive mind’ of senior experts was fascinating:

1. A systems approach to prevention
2. Better governance for prevention
3. Realising the potential of the community
4. Tackling inequalities
5. Tackling multi-morbidities
6. NHS staff health and wellbeing
7. Mental health and wellbeing
8. Smoking
9. Alcohol
10. Early years
11. Health promotion

We set out this shortlist in a discussion paper published before Christmas. It is the first of three we’ll be writing as part of our ‘The Role of the NHS in Prevention’ project, which is being supported by the Health Foundation.

So to the assessment of how well the NHS Long Term Plan measures up against the first five of 11 priorities. (The remaining six priorities will be discussed in tomorrow’s blog.) Like many assessments in blogs it is subjective (sorry) so please do let me know your own thoughts via policy@fph.org.uk.

1. A systems approach to prevention

The NHS Long Term Plan says that its renewed NHS prevention programme has been shaped by the Global Burden of Disease study of the various risk factors that cause premature deaths in England. These risks are smoking, poor diet, high blood pressure, obesity, and alcohol and drug use, with air pollution and lack of exercise also seen as important.

The specificity of the focus for the NHS prevention push is in many ways very welcome. A lack of prioritisation can sometimes prevent non-public health decision-makers from ‘buying-in’ to a prevention agenda. But the biggest message we heard from our workshop experts was that a collection of individual interventions alone will not achieve the change we need to deliver at a population level. This, they argued, requires a systems approach.

FPH’s view is that it isn’t an ‘either or’. We do need to prioritise – and then implement well – prevention interventions that we already know are impactful, cost-effective, and deliverable. If that is the work of, say, the first five years of the ten year plan, it is up to public health leaders to start to explain simply and compellingly what a ‘systems approach’ is now and how it can be adopted by an organisation as complex as the NHS. This could then be the work of years’ six to 10 of the Plan. In return, the NHS needs to be willing to think even more innovatively about how to create a truly prevention-focused NHS.

Verdict: the initial prevention focus on specific individual interventions is understandable and welcome. But there’s significantly more for the public health community and NHS to do in partnership during the second half of the Plan if the aim is to transform the NHS’ approach to prevention.

2. Better governance for prevention

The NHS is full of people passionate about keeping local and national populations healthy and happy. It’s just that this passion for prevention doesn’t necessarily translate sufficiently into how NHS ‘success’ is really measured and how NHS leaders are really rewarded. The Plan talks about an increasing focus by local NHS organisations on population health and on contributing to the government’s ambition of ‘five years of extra healthy life expectancy by 2035’ but there’s not much additional detail.

Importantly, it is not clear how the NHS Long Term Plan and the DHSC’s ‘Prevention is Better than cure’ Vision complement and support each other. As Rachel Chapman and FPH President, John Middleton, argue in their assessment of the Plan, the NHS needs expanded capacity in population health management and public health skills, specialist public health expertise in all NHS institutions, and a ‘dashboard’ for assessing progress against clearly defined prevention milestones and goals.

Verdict: more to do. A good indicator of the NHS’s commitment to population health will be its willingness to take shared responsibility for the outcomes set out in the forthcoming Prevention Green Paper.

3. Realising the potential of the community

The Plan commits to doubling the number of NHS volunteers over the next three years and to scaling-up successful volunteering programmes across the country. The NHS will also continue to work with local charities, social enterprises and community interest companies providing services and support to vulnerable and at-risk groups. There is also a commitment to significantly increase the number of people benefiting from ‘social prescribing’. While all this is welcome, it is difficult not to feel that there remains an untapped opportunity to harness community resources more effectively to improve the population’s health and wellbeing.

Verdict: more to do but the emerging thinking around the NHS as an ‘anchor institution’ shows promise.

4. Tackling inequalities

The Plan makes clear the NHS’s commitment to reducing health inequalities. This is hugely significant, especially as FPH’s recent evidence review found that some NHS prevention programmes can reinforce health inequalities. This new commitment is backed by action. The NHS commits to set out specific, measurable goals for narrowing inequalities and to developing a ‘menu’ of evidence-based interventions to help deliver these goals. The Plan also promises better assessments of local health inequalities, a commitment to reducing inequalities as a pre-condition of new funding, to invest more in areas with high health inequalities, and new action targeted at those who are traditionally left-behind such as homeless people, people with severe mental illness, people with a learning disability and young carers. Expanding key programmes like the Diabetes Prevention Programme are also recognised as an important vehicle for tackling health inequalities given the high prevalence of type 2 diabetes in certain Black, Asian and Minority Ethnic groups.

Verdict: well done NHS! But implementation and monitoring of progress will be key.

5. Tackling multi-morbidities

The plan says it ‘goes further’ on multi-morbidities than the agenda set out in the Five Year Forward View. But it is difficult not to feel that this was an opportunity missed to signal more clearly that this is a key NHS priority for the next 10 years. The Health Foundation argues that the lack of an explicit national strategy to address one of the biggest challenges facing the health services is one of the most significant gaps in the Plan. Of course a month is a long time in healthcare and since the Plan was published NHS England has now published Universal Personalised Care Early feedback from stakeholders suggests it goes some of the way to answering the multi-morbidity criticism.

Verdict: perhaps not as bad as initially appeared.

Click here to read the second part of my blog and in the meantime, share your thoughts via email: policy@fph.org.uk.

Written by Gus Baldwin, Director of Policy and Communications, FPH. You can follow Gus on Twitter @Gus_Baldwin.

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Each year, members of FPH are required to submit a CPD (continuing professional development) return to confirm that they have undertaken CPD activities related to their professional competence and PDP during the previous CPD year. This could be activities like attending a course to learn more about the field of public health relevant to their job role, teaching, audit, reading articles or perhaps getting involved with one of FPH’s many special interest groups.

The CPD requirements of the GMC, and in line with the UKPHR, expect registrants to:

reflect on what you have learnt from your CPD activities and record whether your CPD has had any impact (or is expected to have any impact) on your performance and practice. This will help you assess whether your learning is adding value to the care of your patients/residents and improving the services in which you work.

This is confirmed by the Academy of Medical Royal Colleges and has been adopted and approved by FPH for all our members.

Once the returns have been submitted, around 20% of FPH members are selected to be audited to make sure their reflective notes meet the required standard (in 2019 this is reducing to around 10%).

We are pleased to report that the CPD audit for the year 2017/18 is now complete so we are writing this blog to share feedback with our members. We also want to give advice that will help members submit a successful return in future years.

How many FPH members submitted satisfactory returns?

We are delighted to report that 92% of audit submissions were found to be satisfactory, which is 2% higher than last year. We were also pleased to see that more FPH members are making use of the PDP (personal development plan) element of the online CPD diary. This is something we’ll be encouraging more of our members to do because it helps to explicitly demonstrate the link between CPD and their PDP.

Was there a common reason why CPD returns were unsatisfactory? 

The most common reason CPD returns were assessed as unsatisfactory was because reflective notes were not of a good enough standard.

How do we determine if a reflective note is satisfactory or not?  

FPH’s online CPD diary provides a framework of four questions to help guide members when reflecting on their CPD activities. They are:

1. Why did I choose this activity for my CPD?
2. What did I learn from this activity or event?
3. How am I going to apply this learning in my work?
4. What am I going to do in future to further develop this learning and/or meet any gaps in my knowledge, skills or understanding?

FPH members should reflect on their new learning by answering each of these four questions in the boxes provided.  On page 34 of the Faculty’s current CPD policy (and page 27 of the new policy), there is a very useful table which provides a summary of the characteristics of a good answer to these four questions, so you know what to include.

A satisfactory reflective note is one in which the responses to at least three of these elements are assessed to be either borderline or good.

Lastly, a common observation during the audit was that some of the reflective notes read more like ‘descriptive notes of a learning activity’ as they did not contain any genuine reflection. Reflecting on an activity (what I have learned and what I need to do as a result) is different from reporting on an activity (who did or said what).

You can find examples and tips on writing good reflective notes by clicking here.

We hope that you find this advice helpful and it’s useful when you use your online CPD diary. If you have any questions, please contact your local Regional CPD Adviser.  Contact details can be found here or to download the new CPD Policy, click here.

Written by FPH’s Continuing Professional Development (CPD) Committee.

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The end of 2018 marked the 70th anniversary of the Universal Declaration of Human Rights, the 40th anniversary of the Alma Ata Declaration on primary health care for all, the 23rd anniversary of the Beijing conference on gender and human rights, and the 45th anniversary of the first mobile phone call ever made. The common thread connecting these historical milestones becomes evident against the backdrop of the digital health technologies increasingly being used to strengthen the right to better quality primary health care, especially for women and girls.

Arguably, digital networks and mobile technology have permeated nearly every aspect of people’s lives across the globe. And many digital innovations have been introduced to improve how health services are planned, delivered and received, and even save lives.  

A recently published supplement, Advancing health equity and gender equality: Digital health in the Global South, documents evidence from seven countries from the Global South about what has worked and what hasn’t in terms of the use of digital technology to reduce health and gender inequalities. The authors from Bangladesh, Burkina Faso, Ethiopia, Kenya, Lebanon, Peru and Vietnam used results from five years of research funded by the International Development Research Centre (IDRC) to explore these important questions. The projects focused on access to health services by historically neglected communities who are served by an over-extended and under-resourced health workforce. The answers are, therefore, very helpful to support efforts by the global health community to reach the Sustainable Development Goals (SDGs) by leaving no one behind.  

In Vietnam, for example, a customized Health intervention for ethnic minority women in a mountainous region witnessed improvements in antenatal and postnatal behaviours. The customized text messages and personal follow-up increased women’s confidence to ask questions about their health. The intervention showed that changes in health behaviours and gender norms can help address decades of social exclusion that have been leading to lower health outcomes. Researchers in Peru, for their part, found that providing pregnant indigenous women with access to their health records strengthened their power, ownership and agency. And in Ethiopia, careful analysis allowed researchers to identify the potential negative impacts of a Health intervention on an already overstretched cadre of all female healthcare workers working in rural areas.  

The cohort of seven projects included some cross-cutting analyses that were integrated from the outset. Areas such as health equity, gender analysis, research quality, knowledge translation and cross-grant learning were monitored and supported to improve the potential impact of the results in different communities.  

The overall messages from the supplement are that digital health interventions at primary and secondary health care levels can positively influence health equity, help tackle existing gender inequalities, and create opportunities for new forms of positive power dynamics. But for that to happen, interventions need—at the outset—to be thoughtfully designed and implemented. Questions about inclusion, equity, rights, identity, access, agency and citizenship need to be integrated in the research questions and methodology in order to generate a solid knowledge base about how this could work in different geographic contexts, different populations and for different health challenges.  

The research also showed that digital health should not be based on a top down design. Findings from Burkina Faso and Lebanon pointed out that the chances of success and positive outcomes are commensurate when digital health interventions are based on community engagement, and user-centred models.  

The onus of building the evidence of what works, how, and for whom is on the research community. As digital health in low- and middle-income continues to grow in magnitude, scope and investment, the collection of articles presented in this new supplement also offers insight into areas that would benefit from more research. These include:

1. providing adequate support and incentives to health workers (many of them women) to improve their work through digital health tools
2. examining how using digital health to access and share information can influence agency, decision-making, intra-household dialogue and other types of power dynamics that are central to health and well-being for individuals and their families
3. ensuring that health data are reliably collected and systems can securely share and analyze them to maximize use by community members and by decision-makers, including for reporting on the SDGs.  

If the global health community is to achieve the global goal of ensuring healthy lives and promoting wellbeing for all at all ages, bodies of research like the one presented in this supplement are critical. Research agendas need to evolve with the times and continue to build evidence on how digital health interventions influence health equity and gender equality wherever they are used. The most dazzling technology will always fall short unless it is applied using a people-centred and rights-based approach to public health.   

Written by Chaitali Sinha, Anne-Marie Schryer-Roy and Montasser Kamal. Chaitali and Anne-Marie are guest editors of the Journal of Public Health supplement, Advancing health equity and gender equality: Digital health in the Global South. Montasser is a Program Leader at the International Development Research Centre, Canada.

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It’s been a little over a month since we published our first discussion paper on prevention in the NHS. If you’re one of the many people who have responded to our request for feedback – thank you! We’re very grateful to all of our members and others who have taken the time to answer the questions we pose in the paper and send us their general reflections and thoughts.  

While the feedback has touched on a variety of topics, a good portion of it has focused on what is helping NHS staff and organisations do more prevention or what is getting in their way. It’s pretty clear from the combined feedback that our work needs to not only look at the ‘what’ of delivery, but – and perhaps more importantly – it needs to examine the ‘how’ of delivery.  

Our evidence review into prevention in the NHS identified 15 enablers and over 30 barriers to delivering prevention regardless of the sector in which programmes were implemented or the exact type of programme. Below we pull out some of the key ones that FPH members have told us helps or hinders their work.  

Enablers of good prevention delivery 

1. Good partnership working – We received a lot of feedback about the importance of partnership working to deliver effective prevention and the role that the NHS can play as a partner to others in the community, voluntary, commercial, or statutory sectors and that more should be done to facilitate this type of working. Several people highlighted that within Scotland, the advent of Health and Social Care Partnerships has moved many prevention programmes to a shared responsibility and suggested there was learning from those partnership successes that needed to be explored further.  
2. Using a targeted approach – Having a systematic and individually tailored process for prevention works much better than impersonal messages. Targeting sub-groups with specific needs and ensuring that the initial approach is made by a familiar face can also help. This can be something as simple as ensuring prevention advice is delivered by someone with an established relationship with the patient. Tools like the Heart Age Test where advice is more personalised also seem to work better than generic healthy living campaigns. 
3. Content, access, and location – Making prevention accessible in terms of location, the use of non-technical language, and the use of technology improves uptake and delivery. We heard it’s important to ‘go where people are’ and always seek to address the individual holistically. This is especially important to bear in mind as a lot of prevention programmes exacerbate health inequalities because they are inaccessible to more disadvantaged groups. For example, we heard about Drug and Alcohol Services providing seasonal influenza vaccinations to heroin-dependent service users as part of their routine services – this proved successful in vaccinating a group of people who were considered hard to reach with traditional influenza vaccination programmes.  

Barriers to good prevention delivery 

1. Lack of clarity about who is responsible for prevention – This is a key piece of feedback we’ve heard throughout this project: ‘If prevention is everybody’s business it’s often usually nobody’s job.’ This lack of clarity can often mean that prevention is not integrated fully into core services. This is exacerbated we heard by a lack of clarity around governance for prevention.  
2. A lack of funding – We heard that although funding is not the silver bullet for prevention delivery challenges, many agreed that current remuneration models and a lack of financial resources allocated to prevention were significant barriers to doing more prevention.   
3. Complexity and co-morbidity – Around 25% of us have two or more long-term conditions. This has been flagged as a key implementation issue when it comes to prevention programmes. We’ve been challenged to consider which condition the health and public health system should look to address first in order to ‘unlock’ the most improvements for people with co-morbidities.

We’d love to hear from you 

If you recognise some of these challenges or have examples of some of the enablers in action that you’d be willing to share, please email us at policy@fph.org.uk. Thank you for your feedback so far, it has really helped to shape and progress this work and as always please stay tuned to this blog for further updates.  

Written by Ahmed Razavi, Specialty Registrar in Public Health and member of FPH’s Public Health Funding Project Group.

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practFebruary is Lesbian, Gay, Bisexual and Trans History Month, an annual opportunity to celebrate the contribution of LGBT+ people in history and reflect on how society can become more inclusive of diverse sexual orientations and gender identities. For public health professionals it is a reminder to reflect on how well we service this community in our daily professional practice.

In the last five years we have seen rapid evolution in the language surrounding gender and sexual identity, alongside this a more nuanced understanding from the media and the public of the diversity within the LGBT community.

Sadly the evidence suggests we still have a way to go in terms of community acceptance and inclusion.  The UK Government National LGBT Survey 2017, an online survey which gathered responses from over 108,000 LGBT+ people living in the UK, found that:

• more than two thirds of LGBT+ respondents said they avoid holding hands with a same-sex partner for fear of a negative reaction from others.

• 23% had experienced a negative or mixed reaction from others in the workplace due to being LGBT+ or being thought to be LGBT+.
• At least two in five respondents had experienced an incident because they were LGBT+, such as verbal harassment or physical violence, in the 12 months preceding the survey. However, more than nine in ten of the most serious incidents went unreported, often because respondents thought ‘it happens all the time’.
• 2% of respondents had undergone conversion or reparative therapy in an attempt to ‘cure’ them of being LGBT+, and a further 5% had been offered it.

For public health colleagues these findings shouldn’t come as a surprise. For over two decades the body of evidence, demonstrating significant and persistent health inequalities across physical and mental health affecting LGBT+ people in the UK as well as internationally, has grown in breadth and depth.

Public Health England has consolidated some of the evidence into reports on improving the health of gay and bisexual men, and the health of lesbian and bisexual women, in addition to the reporting of sexual health  and HIV affecting men who have sex with men and a specific guide on screening for trans and non-binary individuals.

There have also been an increasing number of local authorities doing specific LGBT needs assessments, including Stockport, Devon, Reading,  Manchester, Brighton & Hove, which provides a great foundation for action.

The National LGBT Companion Document to the Public Health Outcomes Framework (2013) set out four key recommendations for action which remain relevant today for public health professionals, further strengthened by the growing evidence base:

Recognition

This is more than just specific LGBT needs assessments, it is about recognition of LGBT people in all needs assessments and annual DPH reports, in the same way we routinely consider gender, ethnicity and age.

There are also many areas where intersectionality between different minority identities such as sexual orientation and ethnicity create compounded inequalities, as well as creating opportunities for bridging and collaborative solutions across communities.

It is also important to recognise that LGBT represents four different groups of individuals who share some inequalities but also who experience specific and different levels of inequality.

Engagement

Working with communities is at the core of public health practice, we are professionals for whom engagement is a core skill, yet we don’t always think about specific and targeted engagement with the diversity of the LGBT community.  Being conscious and aware of this may help approach engagement differently, and LGBT history month provides a great way to become more aware of local groups, networks and community organisations who can help you strengthen your conversations with local LGBT people.

Monitoring

Evidence and data are at the core of public health practice, especially when it comes to focusing resources where they are most needed. With the ONS, NHS and local government integrating sexual orientation data collection into routine datasets there is now a stronger body of data to draw upon for the local and national picture. However data is only useful if it’s analysed and it’s incumbent on us as public health practitioners, and commissioners, to ask for this data to look at what is happening to our local LGBT communities.

Service Provision

Finally where public health professionals are engaged in commissioning or providing services it is important to think about how service provision is meeting the needs of LGBT individuals and communities. There is lots of support now available to providers to support them to provide more inclusive and culturally competent services for LGBT people, such as the Pride in Practice Programme and resources from NHS Employers. The concept of progressive universalism can work for LGBT people but only if universal services are culturally competent to meet their needs, and that requires explicit commissioning and monitoring of service use to ensure that LGBT communities are not being left behind.

Across public health we have a duty to address health inequalities and we can only do that effectively if we talk about, and think about, the needs of minority communities and take specific action to address them. LGBT history month is just one month, but it can provide an important prompt for reflection on whether you are doing enough in your daily practice to close the gaps in LGBT health. 

Written by Dr Justin Varney, Fellow of the Faculty of Public Health, HonFOM, and Interim Strategy and Policy Lead, Business in the Community and National Strategic Advisor at Public Health England.

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