Better Health For All

As a paediatric registrar I saw a 10 year old girl exsanguinate. She had been in a high speed road crash in which both her parents had been killed. She was sitting in the back wearing a lap belt. It had ruptured her spleen and liver. She was fully conscious but deathly pale and my job was to look after her airway. She asked, ‘will I be alright?’ and I said, ‘yes – but we need to do an operation to stop the bleeding in your tummy’. I gave her an anaesthetic and took her up to theatre but she died on the table. Her death hit me like a hammer and her memory has lived with me ever since.  

About 20 years later, working with doctors world-wide, we eventually found a safe and effective treatment for acute traumatic bleeding. It might have saved her life. The CRASH-2 trial showed that early administration of the anti-fibrinolytic drug tranexamic acid – usually known as TXA – reduces bleeding deaths by one third. Globally, this cheap generic drug could save over 100,000 lives each year.  

But how do we get this result into practice?  

Because this was the first time we had found a treatment that actually worked in trauma patients, we had never done this before. We had to learn fast. Thankfully I work with some very able and committed people – Professor Haleema Shakur-Still who co-directs the LSHTM (London School of Hygiene and Tropical Medicine) Clinical Trials Unit with me in particular.  We worked with victim organisations, the media, clinicians and policy makers (the Chief Medical Officer, National Clinical Director, NHS Trusts, World Health Organisation). We got tranexamic acid on the WHO List of Essential Medicines. The British Army put TXA into combat care protocols and in 2012, the US Army reviewed the evidence from the CRASH-2 trial and included TXA into its treatment protocols.  

We worked with the road traffic victim’s organisation RoadPeace to monitor the implementation of TXA across the NHS. RoadPeace sent Freedom of Information requests to all NHS trusts on an annual basis asking about TXA use. We lobbied the BBC to include TXA in emergency care soaps such as Holby City and Casualty. We worked with the National Clinical Director for trauma to include TXA in the standard contract for trauma services and with Ambulance Trusts on pre-hospital TXA use (TXA was later included in Ambulance guidelines). Slowly TXA use in the NHS started rising.  

Recent trauma audit data show that TXA use in NHS trauma has increased from zero in 2010 to over 75% in 2016. But there is lots more to do. One major new challenge is to increase the use of tranexamic acid in women with post-partum haemorrhage (PPH) in low and middle income countries. Our second global trial in acute severe bleeding was the WOMAN trial which enrolled 20,000 women with PPH from over 20 countries world-wide. Again we found that tranexamic acid reduces bleeding deaths by one third. Getting research into practice in high income countries is a lot easier than in low and middle income countries where there is poor health service infrastructure but no mother should die for the lack of a drug that costs less than a dollar.  

Winning the Bazalgette Professorship – Champion of Evidence Award – is a real shot in the arm. I had always revered Bazalgette’s contribution to public health and often talk about him to the students. I hope that this award will somehow help us to get TXA to every patient who needs it.  

Written by Ian Roberts, professor of epidemiology and public health, and co-director of the Clinical Trials Unit at LSHTM. Professor Roberts is the first person to be awarded the FPH Bazalgette Professorship Champion of Evidence Award. The Award, presented in collaboration with the Alliance for Useful Evidence, recognises a Fellow of FPH for major contributions to public health policy and/or practice through research translation for the benefit of UK population health. 

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Earlier this month we held our second of three planned half-day workshops examining the role of the NHS in prevention. Building on the findings from our first workshop, this session brought together experts from Public Health England, NHS England’s strategy and innovation directorate, commissioning groups, local authorities, and NHS trusts. Having such expertise in the room contributed to a thoughtful, sometimes provocative, and constructive discussion on NHS prevention. 

We gave attendees a sneak preview of some findings from our recent polling of NHS leaders about prevention and asked attendees for their initial analysis about what we found. We polled NHS leaders about a wide range of prevention aspects, including: their prevention priorities now and for the future, how much they spend on prevention versus how much they would ideally like to spend on prevention, and the barriers they encounter when their teams try to ‘do’ prevention. 

We’re really excited about sharing the findings with you in the next few weeks and hope they will illuminate how NHS leaders see prevention and its importance to their work, along with how they think prevention should be delivered. It was heartening to see the priority given to prevention by NHS leaders outside of public health and this underscored the recognition that preventing ill-health is key to a sustainable NHS.  

FPH’s response to the NHS Long Term Plan was also outlined with a special emphasis on how FPH can contribute to its implementation. I’ll just touch on one of the topics discussed here. Workforce development is one of FPH’s core functions. Through this project, we’ve been hearing that public health input into acute settings varies widely from locality to locality and this has been identified as a critical gap in registrar training. Crucially, we heard, this is not just about FPH trying to increase the footprint of the core public health workforce – although that would be welcome. It’s also about ensuring that clinicians in other specialties, such as general practice and paediatrics, have the public health skills they need to help deliver the prevention agenda.  

The workshop also had a particular focus on untangling some of the thorniest governance challenges NHS organisations face when trying to integrate prevention into ‘business as usual’. We heard in our first workshop that getting the governance for prevention interventions right should be an immediate priority for any NHS organisation seeking to take a systems approach to prevention delivery. Subsequent feedback from FPH members – along with a survey of the healthcare public health workforce – has revealed that ‘governance issues’ are a top barrier to prevention.  

Good governance matters because it leads to more efficient use of public health spending. Making the healthcare system accountable for the health of their local population instead of dealing with disease as and when it arises would help refocus the healthcare system around preventing ill-health from happening in the first place. At our workshop we heard from the team in the East Midlands leading some of the investigative work into what makes the ‘governance machinery’ of the NHS function better for prevention and discussed collaboratively some of the governance challenges teams are facing and the solutions they are looking to implement.  

We will be exploring these topics further, including the opinion polling findings, in a discussion paper due to be published in the next few weeks. Your feedback and comments are what help us shape this work and – as always – we hope you will take a moment to get in touch and let us know what you think. Thank you so much in advance.  

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

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A public health department could be introduced in hospitals all over the world. 

Doctors and public health specialists working together under the umbrella of hospitals can lift a huge burden of diseases off our society and our health budget. Public health specialists could counsel people in the surrounding community (including patients and their caregivers) about preventive measures for maintaining good health. This effort would help people understand the importance of prevention and how it can save them from major diseases. 

During visits for a regular checkup or a simple fever, patients and their caregivers at high risk could be advised by public health specialists about preventive measures. For example, most cases of cardiac disease develop due to a poor diet and sedentary lifestyle. Too often people ignore the symptoms and avoid visiting a doctor. If such cases are detected early on during, say, a routine hospital visit, public health specialists could help people from developing serious conditions. Instead of encouraging people to eat better and exercise after a cardiac disease diagnosis, why not help people when they are still relatively healthy? 

Having public health departments embedded in hospitals could also provide better epidemic prevention and response, resulting in fewer casualties and less panic.  

Public health department in hospitals could comprise of  two sections; 

Section 1: Epidemic Training Cell  

A system could be created so that at times of natural disasters/catastrophes all public health specialists can unite at one platform and use all their abilities to save the affected people from further physical and mental pain. 

This cell is for quick response when epidemic occurs to avoid panic and minimise casualties. In epidemic days it can hold counseling sessions for all patients visiting hospital along with healthy attendants to minimise the spread of epidemic. 

It can also conduct on-the-job training of staff. An example of this is the implementation of the latest program that has been introduced by WHO called IMCI (Integrated Management of Childhood Illness) which has distance learning modules for health workers for better health care delivery. 

Section 2: Disease Prevention Cell  

The aim of this would be to provide health education to prevent people getting sick and/or contracting diseases. An example of this would be educating people on the importance of drinking safe water by using chlorine tablets as a replacement for boiling water.  

This department could work in collaboration with other units such as cardiology, gastroenterology, psychiatry, dermatology, cancer surgery, ophthalmology, gynecology and pediatrics. 

Here are some examples of how this could work in practice; 

Cardiology 

• Patient arrives in Cardiology Emergency Department with chest pain or tachycardia and is sent back after ECG shows no signs of pathology. In the presence of a public health department this patient could be consulted about their weight, habits, physical activity and mental health to avoid development of a major cardiac pathology in future 

Gastroenterology 

• Patient arrives in Gastroenterology Department with epigastric pain and is sent home after being prescribed regular treatment. 
• In the presence of a public health department this patient could be consulted about the importance of boiled/safe water and safe food intake as a preventive measure against Hepatitis and other gastric diseases. 

Cancer surgery 

There is a real life case of a young woman who developed breast cancer. She had a single mastectomy but 10 years later, she developed breast cancer on the other breast and is currently undergoing chemotherapy after surgery. She wasn’t consulted about follow up/looking for warning signs after her first diagnosis but in the presence of a public health department, this patient could have been consulted to avoid future pathology by regular follow ups and looking out for warning signs as early as possible. 

Gynecology and Pediatrics 

• A public health department could educate pregnant women about warning signs to look for during pregnancy, and in their babies to prevent the occurrence of a serious disease. 

• For example, pregnant mothers could be given instructions on how to fulfill the nutritional requirements of themselves during pregnancy and beyond. 

For all of the above departments, infographics and health education posters could be displayed to educate patients and staff as well. 

What would the aims and requirements of a public health department be? 

The staff required for setting up of this department should be qualified in public health or community medicine. 

The main aim of introducing public health departments in hospitals is to prevent development of diseases or their serious forms and give health education to people who are not receiving it at the moment. The focus of hospitals lies on curative treatment but a formal way of giving people health education is missing in our health system. If properly implemented, this could make us a healthy and productive nation and world. 

Written by Dr Sarah Tanvir, MBBS, MPH, Diploma in Best evidence Medical Education, Pakistan.

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Are you interested in creating better mental health for all?  If so, please join our first ever joint Public Health and Psychiatry conference on 10 May at Queen Mary’s University, London, focusing on Prevention: What Works? 

What do we mean by ‘Better Mental Health For All’?  

When mental health makes the headlines it is often owing to healthcare concerns, for example long waiting times for accessing care.  This focus on responding to mental illness is very important, but when considered in isolation it can distort a wider population view of mental health and well-being – one that we are all part of, affected by, and is heavily influenced by our social and economic environment.  Public mental health focuses on mental health improvements for all population groups, as well as targeted and universal approaches to preventing and reducing mental illness. 

So what is the conference about? 

This unique occasion will bring together colleagues from across public health and psychiatry to reflect on and develop plans for how we can continue to collaborate in the creation of better mental health for all.  This will include listening to a range of eminent speakers from across the UK share fascinating examples of collective approaches to improving population mental health, such as: 

1. The introduction of minimum alcohol pricing in Ireland  
2. The role of social prescribing  
3. How different public services are taking innovative and collaborative steps to address adverse childhood experiences.  

The conference will also give attendees a platform to share ideas and perspectives across specialties with regards to the opportunities and challenges of collaborative working.  There is arguably a never more important time for this conference in terms of capitalising on the growing political and societal focus on mental health, as demonstrated in policy documents such as the NHS Long Term Plan.  

What opportunities does this conference offer?  

We asked others across psychiatry, public health and academia:  

Across the whole life span, early life experiences impact on the quality of our relationships, mental health and life chances.   Working in liaison psychiatry in the diverse communities of Luton and Watford, this has been illustrated on a daily basis by the people presenting in crisis in Emergency Departments.  Despite political focus, huge inequalities persist for the people using our services and far too few benefit from timely preventive interventions.  Primary prevention is vital, but so too are secondary and tertiary prevention strategies as there is much need, right now.   Having met many people in both specialties, I believe this truly is a ‘meeting of minds’: two specialties with different skills but shared values.   I’m excited to see how this collaboration develops.

Carol Wilson, Consultant Old Age Psychiatrist, East London NHS Foundation Trust 

Mental health problems have a huge impact on population health, causing significant distress and impairment to large numbers of individuals and their families, as well as having a broader social and economic impact. At the same time, positive mental health and resilience can bring great benefits to the individual and society. Joint working across public health and mental health settings, including the policy, research and practice arenas, is important to help maximise population well-being and to limit the public health impact of mental distress.

Associate Professor John Powell, University of Oxford 

Public mental health still feels in its infancy with much that is untested and contested. There is an imperative to bring the skills of public health and the understanding of psychiatry together to agree jointly what works when and for whom, to improve mental health for everyone. Before the spotlight fades.

Niran Rehill, Specialty Registrar in Public Health, London Kent Surrey & Sussex Training Scheme ST5 

Why is this conference needed?  

One of my main motivations for pursuing a career in public health was to tackle the physical health inequalities experienced by people with mental health problems. During my time working as a mental health nurse I witnessed how the physical health needs of individuals experiencing mental health problems were often neglected, particularly in relation to their health-related behaviours (e.g. smoking, alcohol, diet and physical activity). This conference is an important platform in which to develop joint strategies to address physical health inequalities amongst people with mental health problems.

Claire Mawditt, Public Health Specialty Registrar, ST2 

From listening to mental health service users, their families and those caring for them, there seems to be two predominant conversations gaining traction. Firstly, the potential for community organisations to contribute to preventing and supporting population mental health such as schools, sports clubs, barbers, gardening groups and parenting forums. Secondly, the growing recognition of the importance of a life course approach to mental health to build capacity in early identification of mental health problems and early support. The conference provides a platform to take these conversations further to develop a trans-disciplinary approach to addressing these issues.  

Lucie Collinson, Public Health Specialty Registrar, ST5. 

Written by Laura Austin Croft, Lucie Collinson and Claire Mawditt on behalf of the Faculty of Public Health Public Mental Health Special Interest Group.  

The conference is at Queen Mary’s University (E1 4NS) from 10am to 4pm and is free to attend, but places are rapidly running out.  Please book a place by clicking here. 

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The Suzy Lamplugh Trust is due to host a Stalking Awareness Conference on 9 April 2019 in London. The timing of the Conference is pertinent, as it follows the passage of the Stalking Protection Bill in March 2019, designed to strengthen the law and protect victims of stalking.  

This year’s Conference theme is about stalking as a public health issue, which will present opportunities for policy makers, practitioners and experts within the health community across government departments, clinical commissioning groups and local government to meet and begin contributing to dialogue and solutions to mitigate the sheer impact of stalking.    

A joint report on key findings from ‘Stalking and Health – Understanding the impact’ (based on a survey conducted between January and March 2019), will be launched at the Conference. The report by the National Stalking Consortium (which includes the Alice Ruggles Trust, Suzy Lamplugh Trust and National Centre for Cyberstalking Research amongst other stakeholders) will highlight statistics and conditions on mental health due to stalking. It concludes that front line teams (across all public services) need guidance and training enabling them to better assist those being stalked – thereby reducing cases of PTSD, depressions, as well as femicides on what is a largely gendered crime. 

Suzy Lamplugh Trust defines Stalking as “A pattern of fixated and obsessive behaviour which is intrusive and causes fear of violence or engenders alarm and distress in the victim”.

Stalking is a public health issue which has a huge impact on health and well being of victims. It differs from harassment in that a perpetrator of stalking will be obsessed with or have a fixation on the individual(s) they are targeting. Stalking can take place in many forms, affecting all aspects of everyday life. 

Research has shown: 

• Stalking is one of the most common forms of interpersonal violence in the UK affecting 1 in 5 women and 1 in 10 men across their lifetime
• A reported 1.1 million people experience stalking in England and Wales each year; 734,000 women and 388,000 men.
• Those experiencing stalking can display symptoms in line with PTSD, anxiety and depression

Suzy Lamplugh Trust has been influencing UK policy for over two decades; including campaigning for the introduction of the Protection of Harassment Act 1997, amended in 2012 to make stalking a criminal offence for the first time. In 2019, the Law around stalking was strengthened to further protect victims at an early stage. The Trust has been running the National Stalking Helpline since its launch in 2010, supporting around 30,000 victims of stalking so far.  

Our work continues, and the National Stalking Awareness Conference 2019 aims to highlight the impact of stalking; challenge and improve existing understanding of stalking within the Health sector for victims as well as perpetrators and focus on addressing the lack of specialist health services for victims of stalking. Please find more information and book your ticket here. 

Written by Sara Hindley, Training and Marketing Assistant, Suzy Lamplugh Trust.

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