Better Health For All

The health burden of the current pandemic will extend far beyond the direct impact of COVID-19 morbidity and mortality. We must use evidence to mitigate the wider, indirect effects to protect and improve the long-term health of our population.  

The UK has recently recorded increases in confirmed cases, hospital admissions and deaths from COVID-19. A second wave of the pandemic, with severe health consequences, is underway.  

Leadership is needed to reduce both direct and indirect harms to population health. Unfortunately, political and scientific debates have been unhelpfully framed as a trade-off between controlling the pandemic and minimising the wider consequences of our policy response. In fact, we need both a strong direct response to the pandemic and strong measures to mitigate its indirect impacts. However, the role of evidence-based public health leadership has been much clearer in the former than in the latter.     

This lack of clarity matters because the indirect health effects of COVID-19 are substantial. Frameworks published in April and June anticipated and outlined an array of short, medium, and long-term health and equity effects arising from the pandemic and resulting control measures. There is now a growing evidence base modelling the scale of these impacts or demonstrating them in practice.  Some effects have been felt already, and some will be seen in the long term. They include: 

• displaced healthcare services, and decreased use of remaining services, for example leading to excess mortality from cancer or cardiovascular disease in addition to wellbeing impacts from losses to community services.   
• mental health effects – including in children – arising from social isolation, uncertainty, economic insecurity, bereavement, anxiety about exposure to the virus and working conditions 
• changing or inequitable access to green space, physical activity and healthy food; and new patterns of alcohol use, smoking and gambling  
• changes in exposure to environmental health hazards including overcrowded or poor-quality housing, or temporary accommodation  
• economic and employment impacts, which are inextricably linked with health outcomes
• long-term effects on the life chances and health of a generation of children and young people arising from educational disruption, loss of social contact, missed safeguarding opportunities, and exclusion from the workforce. 

Just as there is evidence that the direct effects of COVID-19 are disproportionately felt by some social groups, there is also evidence that the indirect effects harm some more than others, often reflecting existing inequalities. The initial weeks of lockdown in the UK saw a clear socioeconomic gradient in adversities related to basic needs such as access to food and medication. Consequences for Black, Asian and Minority Ethnic communities have also been profound. Impacts on other groups may be specific to the current crisis: for example, young workers, women, and low earners are more likely to have been employed in sectors that were shut down as part of the government’s response.  

Importantly, there are national and local examples of measures to mitigate potential risks to both short and long-term population health. National and regional initiatives include tenancy protection for renters, emergency accommodation for rough sleepers and job protection schemes.  

A second wave brings an urgent need to draw on this evidence and good practice about the indirect population health impacts of COVID-19 and how to mitigate them. As policies and support schemes change, focus is needed on populations that may become newly vulnerable. But at the time this analysis is most needed, the capacity to carry it out is insufficient at both national and local level.  

Technical advice to UK governments comes from the Scientific Advisory Group for Emergencies (SAGE). SAGE has multiple subgroups ranging from epidemiological modelling, to behavioural responses, to infection control. It does not have a subgroup on wider public health consequences.  

Public Health England should be the organisation best placed to consider wider population health in England. It has produced useful resources to understand and mitigate the pandemic’s impacts. However, it is being disbanded and the future of its health improvement functions remains undecided.  

At local level, Directors of Public Health have an important leadership role. Unfortunately, their teams have seen their long-term resilience eroded by funding cuts, and many frontline staff have been diverted to support the direct pandemic response. Other public services including healthcare, social care, education and housing have an important role here, and are also stretched. 

National, regional and local public health capacity is needed now to help translate evidence of the wider pandemic impacts into concrete action across different sectors. If we fail to learn from the first wave, we risk exacerbating the impacts of the pandemic and doing unnecessary harm to mental and physical health for years to come. 

Written by

Emily Humphreys, Imperial College Healthcare NHS Foundation Trust (@emilyjhumphreys) 

Hannah Barton, Imperial College Healthcare NHS Foundation Trust (@Hannah_EB1) 

Ellen Bloomer, London Borough of Newham  

Fran Bury, Imperial College Healthcare NHS Foundation Trust (@audacityofboats) 

Aideen Dunne, Imperial College Healthcare NHS Foundation Trust (@dunnea9) 

Katie Ferguson, Imperial College Healthcare NHS Foundation Trust  

Suzanne Tang, Imperial College Healthcare NHS Foundation Trust (@suzannestang) 

This article is based on the findings from a series of rapid evidence reviews and consultation conversations with key London stakeholders, exploring the wider impacts of the pandemic and the considerations for recovery, within the context of improving population outcomes. The full report is available here.

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This is anything but a typical year and we all want to protect ourselves and those close to us.

Receiving the flu vaccine is more important than ever before because of co-circulation of COVID-19 and flu. The flu vaccine will help reduce pressure on health and social care during a challenging time and by reducing transmission of flu, help to protect some of the most vulnerable in our community. Those most at risk from flu are also most vulnerable to COVID-19. We must do all we can to help protect them this winter.

Therefore, the Health and Social Care Workers flu vaccination campaign is more important than ever. The flu virus spreads from person-to-person, even amongst those not showing any symptoms. For frontline workers, there is an increased risk of contracting flu and it’s very easy for individuals to pass the virus on without knowing. Even if they’re healthy, they can still get flu and spread it to the people they care for, their colleagues and to their family. This year, more than ever, we are stressing that getting the flu jab is simple, easy and free to those eligible.

For the campaign we carried out research to understand health and social care workers’ barriers to and motivations for getting the flu vaccination in this unusual environment. The research brought out the need to promote a protection-based message, as well as the message that many with the flu can be asymptomatic. This insight has helped shape our creative, communications, and partner assets to ensure they are effective as possible in encouraging uptake of the flu vaccine. Also, a new range of adaptable materials have been provided to allow communication teams to promote local information or new ways for staff to get vaccinated. We knew the flu vaccination may be offered in slightly different ways than previous years, whether that’s easier access for social care workers or hospitals hosting vaccinations in an outdoor marquee!

Due the current environment and the extended eligibility of the social care workforce, we’ve worked even more extensively with Department of Health and Social Care (DHSC) and NHS England & Improvement (NHS E&I). We want to ensure that all communication opportunities are being used to engage and that the sectors are aligned. This can be seen at campaign launch where NHS E&I released an open letter from senior clinicians, sent to all NHS frontline staff alongside a short video by Chief Nursing Officer, Ruth May, promoting the programme. DHSC also released a video from Deputy Chief Medical Officer, Prof. Van-Tam and sent targeted communications to social care organisations and workers.

The Health and Social Care Workers flu vaccination campaign launched on the 16th September and has attracted widespread positive attention from the start with comment from Secretary of State, content across trade media, social media as well as communications from employers, sector stakeholders and representative bodies. There has already been a huge increase in demand for campaign resources, with some assets seeing well over double the amount of orders compared to the previous year. For anyone looking to deliver their own local Health and social care worker flu vaccination campaign, please visit Public Health England’s Campaign Resource Centre for access to toolkits, campaign resources and more.

Written by Public Health England

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A summary  

More than 350 people registered for the Faculty of Public Health emergency webinar on the impacts of a Crashout Brexit on October 19^th.  They came from more than 20 countries  and  three continents reflecting the huge international as well as UK interest in this imminent potential disaster.  The webinar was made all the more timely by  growing  concerns about the risks of a crash out,  from food, manufacturing and haulage sectors. The Prime Minister’s speech on October 16^th made the subject all the more urgent and compelling.   

Professor Tamara Hervey, Jean Monnet Professor of European Law at Sheffield University presented current legal implications of Brexit and crash out. The European  Union is a rules-based organisation. The European Parliament must agree trade deal proposals recommended by the European Commission for implementation by January  1^st 2021.  So time runs out soon. Key sticking points are fisheries, ‘level playing field’, and the governance of the agreement. We risk a crash out  Brexit by default, or by accident. No deal means trading by the World Trade Organisation’s rules, which do not prioritise health. Tariffs are automatically applied on traded goods. The EU has published over 100 sector-specific stakeholder preparedness notices during the Article 50 negotiations with the United Kingdom, suggesting it is serious that no deal could happen. Even if a deal is struck there is no provision for cooperation on broader public health matters, such as tobacco regulation or communicable disease control. Brexit, and specifically the UK Internal Market Bill, affects Scottish and Welsh government aspirations for Continuity with European regulations and may jeopardise existing public health measures there, such as minimum alcohol unit pricing. 

Dr May Van Schalkwyk reprised some of the concerns of her paper with the FPH president and others and added in a few more up to the minute and with a COVID pandemic now added to the mix. Uncertainty always affects mental health. Multiple shocks as we would potential see with Crash-out Brexit on top of the COVID second wave would compound and accelerate each other. A poor or weak deal would only be marginally better than no deal in terms of the disruption anticipated at our ports and the far reaching negative impacts on our economy. There would be disruption to  trade and to supply chains in many aspects of the  economy and important  institutional  links will be weakened or broken. There is strong possibility of shortages of food,  medicines, and components for manufacturing industry. There will also be the possibility of civil unrest., consequent on food shortage and  continuing austerity.   

Maintaining public morale, is intricately linked to public mental health, and community engagement and involvement, and trust, is vital. The WHO has emphasised that the science alone will not beat the pandemic, and that authorities need courage and empathy, and that community participation will be critical in our ongoing public health efforts – the importance of community involvement will only be heighten in the event of a no deal Brexit.  We also need to maintain communication within the UK,  and internationally. Public health, NHS and care services need to be fully involved in Local Resilience Partnerships.  

Professor Tim Lang highlighted the potential catastrophe ahead for food supplies in the short term. The UK is poorly prepared, totally reliant on private sector food retail supply and just-in-time supply chains.  Food poverty is rocketing. Food resilience is not seen as a government or collective problem but as a more individualised and ad hoc challenge for charity. Even without shortages, the fear of shortage and panic buying are a known possibility from this year’s COVID experience. UK food supplies are heavily reliant on the  EU.  Key foods likely to be disrupted are fruit and vegetables coming in and Welsh and Scottish lamb and beef going out. Under World Trade organisation rules, tariffs are automatically applied.  The average import tariffs  from the EU could be  20%. Welsh and Scottish lamb and beef could attract a 48% charge on export to the EU.     

In a no-deal, the immediate impact will be build up of trucks at Dover; a two minute delay to throughput quickly leads to a lorry queue of up to 7000 trucks, according to the “reasonable worst case scenario”.  

There are public health implications: air pollution and congestion, frustration, anger, local unrest and with sanitary provision only just being considered for truck drivers.   

Tim went on to describe a vision for an alternative vision for a post Brexit Britain, noting the continued absence of the much-delayed (English) National Food Strategy, now expected in early 2021.    

Gary McFarlane, Director for the Northern Ireland Chartered Institute of  Environmental Health described similar concerns for food, environmental and consumer safety. He feared a burgeoning workload for EHOs in local authorities , generally in response to COVID and then with added possible Crashout. Some EU systems are still central to for example, food safety. For example the EU RASFF system provided  vital early warning on  food  safety concerns. In a crashout scenario we could lose this and ist still unclear whether a viable replacement exists. Even as part of the EU food crime still goes on. The EU had not been able to stamp  out food crime, as exemplified by the ‘horsegate’ scandal,  but coming out of the EU  will make control of criminal activity even more difficult. CIEH was concerned that even within the EU inadequate progress had been made with regard to securing healthier diets, for human and planetary health. In the current emergency, CIEH was concerned for all aspects of environmental health control at all UK ports-extension of inspection times, congestion, increased air pollution and poor sanitary conditions.for truck drivers. The concerns that have been articulated in terms of delays at channel ports could/will also apply to ports like Holyhead and Liverpool where goods will move from GB to Ireland and Northern Ireland. And we must remember the potential consequences of no trade deal on the availability and price of food in Northern Ireland if it is coming from GB. CIEH would work with FPH to develop food standards to aim for Tim’s vision of an exemplary food policy for Britain. 

What can the Faculty of Public Health do?  

In the short term, the Faculty should advocate for, and reinforce the need for actions locally and regionally, funded and supported from central government. They could work with other public health bodies such as CIEH to amplify this message. 

Public health professionals at local authority and regional level should ensure Local  Resilience Forums have active public health involvement. The LRPs should incorporate food resilience planning in their emergency plans. Children’s Safeguarding Boards should also be mindful of the mental health needs of children,  the need to plan for local food insecurity and children’s food poverty and hunger and address it.   

LRPs need to be aware of the state of local public mental health, severely challenged in the COVID lockdowns. LRPS need to plan for more visible and widespread civil unrest in the light of a no-deal Brexit.  

Public health professionals should advocate for greater financial and service support  to local community groups, to enable enhanced mutual aid programmes to be delivered.   

In the longer term    

FPH should continue to advocate for a National Food Policy. This should promote sustainable diets as basis for food policy at all levels – linking nutrition to ecosystems, social and economic criteria. FPH should also support the https://www.sustainweb.org/news/oct20-future- british-standards-coalition-interim-report/.  

Leaving the EU creates an opportunity for public health experimentation, from which other countries can learn, and for attuning policy and law very closely to population needs in Scotland and Wales, where health is a devolved power. But the Internal Market Bill takes away this opportunity, and disrupts the UK’s devolved constitutional settlement in a way which it is difficult to challenge legally, given the way that the Supreme Court treats these constitutional rules. 

FPH will need to reactivate its lobbying to keep the UK as part of the European Centre for Disease Control and Surveillance ECDC and other European  public health institutions like the European Monitoring Centre for Drugs and Drug Addiction EMCDDA, Lisbon.  Our government can pay the subs to rejoin. 

We will also need to see where we can judiciously test the  ‘Do no harm’ criteria  to future trade regulations– even if the lobby seems like it was from a different era.   

The legal implications for public health are in one sense the same as they have always been. Brexit is bad for the NHS and bad for public health. 

Brexit, in any form, is a form of major social change and transition and has, and will continue to have, major impacts on people’s lives and the wider determinants of health. Public health has a role in keeping health on the agenda at times of transition and at the heart of policy debates and implementation. It has never been more needed. 

Postscript   

Since our Webinar,  EU  negotiator  Michel Barnier has  been in London for a further round of talks;  there is speculation that Prime Minister  Johnson will  hold off any decision on a crashout Brexit until after the  US election; and a large scale national campaign, led by footballer Marcus Rashford to  provide free school meals  has received widespread local authority support– perhaps  providing the impetus fro local  food  distribution platforms of the kind envisaged by FPH. 

Written by

Professor John Middleton, Hon FFPH
President, Association of Schools of  Public Health in the European Region, (ASPHER)  john.middleton@aspher.org 
Immediate Past President,  UK Faculty of Public Health 

Professor  Maggie  Rae  
President, UK Faculty of  Public Health  
President@fph.org.uk  

With thanks to the presenters, Professor Tamara Hervey, Dr  May  Van Zwalwyck, Prof Tim Lang and Mr Gary McFarlane.  

Especial thanks  to the staff team at the UK Faculty of  Public Health who made it happen Mag Connolly, Keith Carter, David Parkinson and  James Gore.  

Thanks also to Paul  Lincoln and  Heather  Lodge, for  PETRA and  Dr Ibraheem Alghamdi for  helpful comments. 

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This blog has been prepared for the SIG by Woody Caan, Liam Hughes and Lina Martino in response to World Mental Health Day on 10th October 2020, which emphasized the importance of advocacy for mental health in the era of Covid-19. The Faculty has had a good track record in recent years for supporting public mental health, and recognizing the interactions between mental and physical health in the spirit of “Equally Well”. It is encouraged to tackle Covid-19 through advocacy for integrated policies and better resources for mental health as an integral part of the proposed national investments to fight the pandemic.

Covid-19 has had a deep impact on individuals, families and communities, and on health professionals and their front-line colleagues in all parts of the U.K. As more has been learned about the disease, it has become more apparent that it has generated major mental health issues, and that these are likely to continue for many more months. Some examples are given below:

• Inpatients have experienced major trauma, with associated mental health symptoms (such as cognitive disruption, anxiety and depression, and for some PTSD) which extend well beyond discharge.
  
• Those living in the community with mild symptoms of Covid-19 may experience a “long tail” of reported physical and psychological symptoms including respiratory damage and renal failure, fatigue and muscle soreness, and cognitive impairment and “mind fog”. Often, they report that clinicians do not seem to take their reports seriously.
  
• Bereavement is an issue for relatives, friends and the wider community, especially given the constraints of social isolation, and there is good evidence about what can be done to help, at pace and scale (and at low cost).
  
• Suicide rates are likely to rise as social uncertainty intensifies, unemployment increases and social protection is scaled back.
  
• There are reports of rising mental health pressures on children and adolescents as they return to school, concern that the diversion of health visitors and school nurses into hospital roles will leave schools and community teams under-resourced, and reports of the delayed return of SEND pupils with complex needs.
  
  The pandemic has exacerbated long-standing health inequalities, including in mental health and wellbeing. A national survey by Mind revealed that existing inequalities in housing, employment, finances and other issues have had a greater impact on people from Black, Asian & Minority Ethnic (BAME) groups than on white people. The reduction in access to health and wider services due to control measures is also likely to have a disproportionate impact on BAME groups and people with severe mental illness.
  
  The concern of members of the Mental Health SIG is that the mental health dimensions of Covid-19 (and the associated resource requirements) may be missed by policymakers, planners and commissioners. Faculty members are encouraged to reflect on what they can do to reinforce the message that the fight against Covid-19 requires attention to mental as well as physical health.
  
  Resources on Covid-19 and mental health, including guidance on public and workforce wellbeing, can be found on the SIG’s web page: https://www.fph.org.uk/policy-campaigns/special-interest-groups/special-interest-groups-list/public-mental-health-special-interest-group/mental-health-and-covid-19/

Woody Caan, Liam Hughes and Lina Martino
FPH Mental Health SIG

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