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Archive for the ‘Health Protection’ Category

Health protection is a global issue – and there are lessons to learn and share from all incidents, wherever they occur. That was the message from the global health protection workshop at FPH’s annual conference in Cardiff on 19 July.

Delegates heard how the Health Protection Agency (HPA) has built a worldwide reputation for its work, in part because the global nature of health protection means that planning needs to go beyond national borders. The World Health Organisation has 10 collaborating centres in the UK, while the HPA has sent teams on international secondments to South Africa, India and Australia. One of the speakers talked about how the HPA had been involved in giving high-level advice to government agencies after the earthquake and nuclear power failure in Fukushima.

Closer to home, the delegates heard from Dr Sarah Finlay about how she and her colleagues from the charity Festival Medical Services dealt with an outbreak of H1N1 at the Glastonbury festival in 2009. The festival had a population of 135,000 ticket holders, and 35,000 artists and staff, many of whom were the kind of healthy, young people most likely to contract the virus. The infrastructure of the event meant that living conditions were poor. People’s behaviour, as would be expected at a music festival, was not typical. The combined circumstances meant that it was easy for communicable diseases to transfer.

Risk was mitigated by following the protocols for managing H1N1, having immediate access to antiviral stocks and good transport to the onsite medical facilities, despite the mud. Good advice was given to festival goers before, during and after the festival, stressing the ‘Catch It. Kill It. Bin It.’ message and the importance of using the hand gels that were available across the site.

Information was circulated via the Glastonbury festival website, music press and general media. Just as the HPA team working on Fukushima had regular updates throughout each day to share information, so the Glastonbury health team relied on situation updates three times each day.

There were six cases of swine ‘flu at Glastonbury in 2009, all of which were confirmed by laboratory test results and each of whom left the site for further treatment. One of these cases was a 16-year old girl who had been sharing a tepee with 12 other people, each of whom had to be tracked down in the chaos of festival life.

In the circumstances, the team felt the outbreak had been well managed, and the lessons learnt from this example of mass gathering medicine were shared with the organisers of the Berlin World Athletics and the Hadj.

Dr Finlay summed up by saying that the success of the festival’s approach to H1N1 was due to having a well thought-through approach, early detection, awareness of the issue and by sharing the lessons learnt.

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by John Middleton, Vice-President of the Faculty of Public Health

The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Wordcloud: Adjusted responses (phrases/themed/categorized), first 200 responses (max 50 phrases)

Credit: Andrew Hood, using wordle.net

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now.  The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
•    An independent and robust Public Health England;
•    A coherent career and training structure for public health professionals;
•    Protection of terms and conditions of staff;
•    Directors of public health reporting to chief executives of councils,
•    Clarity in the size and applications of the ring fenced budget and
•    Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage.  However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began.   NHS planning has historically relied on regulations and guidance, not legislation.  This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog.  It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.

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By Mark Weiss, FPH Policy Officer

As the Health and Social Care Bill makes its journey through the Committee Stage at the House of Lords, FPH continues to actively engage with members, key stakeholders, parliamentarians, as well as through its representation on strategic working groups and supported by its wider media work.

Committed to ensuring the Bill will provide the structures and safeguards necessary to protect and improve the health and wellbeing of the people of England, FPH is working hard to ensure a strong and viable public health workforce is maintained and strengthened for the future; and a rigorous framework for the statutory registration and regulation of all public health specialists to protect the public is established. 

As we continue to press hard for amendments to the Bill, at the forefront of our minds the risks to the public posed by the Bill – E.Coli, SARS, pandemic flu, Buncefield, heatwaves, flooding, immunisation and screening – loom large. To meet this challenge, with Lord Patel taking a lead on FPH’s amendments, we maintain a focus on statutory regulation; the role, qualifications and accountability of directors of public health; the organisation independent of Public Health England; public health expertise in the new NHS Commissioning Board; employment conditions for public health professionals at parity with the NHS.

Over the past few months, FPH has developed and implemented a firm lobbying strategy. We have written to all MPs and peers taking part in the Health Bill readings in both the House of Commons and Lords, setting out a clear case for our amendments to the Bill. We have the support of a broad range of peers from across all political parties – and have regular meetings with peers to discuss the possible impacts of the Bill in the context of public health.

We are also working with other health and public health organisations through our chairing of the PHMCC task group, and actively engaging with local government colleagues – including producing a joint statement with the Local Government Group. We also have representatives on key strategic groups, including the Public Health England Group (feeding into the development of the PHE Outcomes Framework) and the Workforce Advisory Group and have taken an active involvement in the NHS Future Forum Process with a submission recently sent in for the Second stage. FPH also maintains close working relationships with other faculties, Royal Colleges and stakeholders to share information and horizon-scan.

Informing our position, three member surveys have been conducted to ensure that we are engaging our members in a full and meaningful dialogue. At present we are in the process of analysing the results of our latest survey of members’ views of the Health Bill, with a full analysis to follow shortly. In addition, FPH works closely with its Local Board Members to encourage their active engagement with local MPs and relevant stakeholders.

Our lobbying work around the Bill has been supported by our wider media work, delivering news articles including a recent response to the Health Select Committee 12th Report on Public Health appearing in the Guardian (a copy at this link); and letter to the Times outlining our key concerns with the Bill. In turn our monthly bulletin continues to keep all of our 3,500 members abreast of the latest developments.

For all the latest news on our work on the reforms visit www.fph.org.uk

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By Dr John Middleton, FPH Vice President

A perfect storm has been brewing over the summer about press invasions of privacy and corrupt police practices.  But if the public and politicians are concerned about the threat to their privacy how much more should they be concerned about the threat to their health?

In its response to the public health white paper consultation,  The Way Forward, the Department of Health says effectively: “Show us more evidence that regulation of public health professionals is required.”  Was the Secretary of State not in the House on Wednesday 13  July?  Or lurking in the corridors of power for the select committee interrogation of the Murdochs on 19 July?   Has he not heard the pronouncements of the Prime Minister about the regulation of the press? Do these not offer any clues on the need for regulation of public health specialists?  The story below is from the Health Service Journal in the autumn of 2016…

“In separate incidents around the country  – the UK public health system has failed to stop major outbreaks of tuberculosis, E coli hemolytic uremic syndrome and salmonella. There have been high-profile deaths from the failure to immunize against measles. Major screening disasters have seen deaths of women from preventable cervical and breast cancers.  Public concern has been heightened by further allegations that local health and wellbeing board strategies have failed to identify people at highest risk of coronary heart disease and so implement the most effective strategies for preventing death and disability.  Public safety was compromised when the Government refused to take action to regulate all public health specialist practice.  Local authorities handed public health duties to assistant directors in council services without formal and approved public health qualifications, to agreed national standards.

“The prime minister, under pressure from unprecedented public concern made the following statement yesterday: ‘Not the smallest freedom we cherish in this country is the freedom to be alive. People who were not fit and proper were allowed to undertake vital roles in securing public health safety, in setting priorities for local authorities to determine which life-saving services they should invest in and advise clinical commissioning groups where the best choices to save lives were to be made.

“‘I am determined that this government will take the following actions. One: action will be taken to get to the bottom of the specific revelations and allegations about incompetent management of infectious-disease outbreaks, poor surveillance of major public health problems and inadequate advice to health and wellbeing boards and clinical commissioners to determine where local government and health services should have spent their money. Two: action will be taken to learn wider lessons for the future of the public health profession in this country.  And three: that there will be clarity – real clarity – about how all this has come to pass and the responsibilities we all have for the future.

“‘…We need action as well to learn the wider lessons for the future. In particular, we should look at how our public health services are regulated and make recommendations… Of course it is vital that our public health specialists are independent. But public health freedom does not mean that public health should be above the law. Yes, there is much excellent public health practice in Britain today. But I think it’s now clear to everyone that the way public health is regulated is not working. Let’s be honest, voluntary regulation has failed. In these cases it was, frankly, completely absent. Therefore we have to conclude that it is ineffective and lacking in rigour. There is a strong case for saying it is institutionally conflicted. As a result, it lacks public confidence. So I believe we need a new system entirely.

“‘For people watching this scandal unfold, there is something disturbing about what they see. Just think of those in whom they put their trust: the politicians to represent them and Public Health England and local authority public health to inform them and protect them. All of them have let them down.

“‘…I want a regulatory system that is statutory and ensures the safety of the public’s health that has proved itself beyond reproach… a political system that people feel is on their side… and public health practitioners that are, yes, independent and rigorous, that investigate and protect, …that hold those in power to account and occasionally – yes, even regularly – drive them mad, but, in the end, are an independent professional public health service that are also clean and trustworthy. That is what people want. That is what I want. And I will not rest until we get it.’

“The BBC’s political editor asked the question: ‘Prime minister,  isn’t that what the Scally report recommended in 2010?'”

The NHS Futures Forum got it.  The Government refused to accept its recommendation.  The Way Forward document still asks for more evidence that public health needs statutory regulation across all its professionals.  Public health is life-saving business.  The public deserves to be protected. The professionals deserve protection from themselves. Their employers need protection through assurance of standards and regulation.  What’s right for the press is right also for the public’s health.

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Monkey drinks Cola in Addis Ababa

A monkey drinks cola in Addis Ababa

By Dr Jackie Spiby

Hello from Addis Ababa.

It is a warm and sunny morning. By lunchtime it will be hot, but not too hot as we are 2,400m high and there is usually a breeze. When I go out it will be dusty, smelly and, if I noticed it anymore, the air will be polluted. This is mainly due to the huge volume of taxis, buses and lorries, most of which are ancient and belch out dark smoke which hangs around the city. I walk everywhere or go on a crowded, filthy line-taxi; so am I green? I came on a plane so blew my green travel limit and I use plastic water bottles – well I have to as I can’t drink the water but I do boil and filter so I reuse the bottles. Plastic bottles are everywhere.

I am a VSO volunteer and working in a local NGO (though virtually totally funded by external donors).  After 32 years in the NHS it was time for a change. For me that is, not the NHS because, as we know, that happens all the time. It took some time getting through the VSO process especially as my husband is here as an accompanying partner. Attending the assessment day together was a new experience. Try doing a group activity (you know one of those management games) with your partner. VSO then sends your CV out to local VSO programmes for them to see if they want you. You don’t get a choice; you just get to say yes or no to an offer. The first one was way outside of my experience, the next we had to go in five weeks; the next wasn’t viable for my husband.  Despair; but finally Ethiopia came up, an HIV organisation at national level and a country of spectacular scenery with mountains. It wasn’t the Far East which was my preference but we are here and at some point we will get to the mountains.

I am working in an organisation called the Network of Networks of People Living with HIV (PLHIV) or NEP+ for short. The HIV epidemic in Africa is heterosexual. When it emerged in the early ’90s there were no HIV services.  PLHIV started to form groups to help themselves and a few very brave souls (many of whom are dead now) came out and said that they were positive and demanded acceptance and support. My organisation arose out of the formation of these groups. There are nine regional networks, two city networks and three national ones with some 400 local networks. Civil engagement is one area of activity but primarily they are organisations that help provide prevention, treatment and care as well as projects to increase skills and employability. However, that is changing as the government starts to provide a health service. So, as ever, an organisation in change.  To think I didn’t know about the Global Fund six months ago and now I can quote the rules chapter and verse.

HIV is about poverty here, the treatment may be free but food and shelter are not and many PLHIV can’t afford the basics. Nor is the treatment for opportunistic infections free, so TB and malaria are the main killers.

So here I am. NEP+ is some 30 people – all Ethiopian, except me. It is primarily male, except me. Originally the organisation’s staff were PLHIV. As the donors started to require financial statements, governance and the like, the professionals arrived. Now the balance has changed. Is that right? Should there be positive discrimination toward PLHIVs? Can someone who is sero-negative really know or understand what it is like to be positive or even what it is like to live in a family affected by HIV? All questions that I remember discussing in the ’80s when working at the King’s Fund. All answers gratefully received.

Now more and more HIV infected people are getting treatment and living. But there are still 14,000 HIV-positive babies born a year. In the UK and US the numbers are way below a hundred. Why? Many women don’t use antenatal services or won’t get tested. Why? Lots of reasons but for some their husbands won’t let them, accessing services is too difficult or their families tell them to use traditional services. Even if a woman is diagnosed, follow up is logistically difficult and complying to the full treatment and breast feeding regime complex in a developed country, let alone a rural village with no water or electricity. The net result is a take up of about 12% of prevention-of-mother-to-child-transmission treatment. One of the worst levels in Africa. Tragedy. All those avoidable deaths and HIV+ kids, let alone the number of women who don’t get treatment. The number of orphans is horrendous. The international, political voice on this one just isn’t there.

VSO volunteers work in local organisations and are paid a stipend which is equivalent to local salaries. So I am paid the same as our drivers, but I do get accommodation. That means we live and work in the community much more than the majority of ex-pats (called Farangis here) who work for international NGOS, the private sector or embassies. I think I am going native as I am starting to really empathise with my colleagues as we try to use the EU process for submitting a bid on a slow dial-up computer link or listen to a well-meaning expert from a big international NGO tell us we must do more on civil rights. Of course we should but at the risk of immediate shut down. There is a law forbidding NGOS to speak about civil rights. A classic case of can you do more inside the system or outside.  Only here is it outside the system but in the country or outside internationally? Oh I have a lot of learning to do.

Public health issues are everywhere including my diet. My hips are vanishing as my diet has drastically changed to minimal dairy with fruit, veg and carbs instead. Having had a fractured hip a couple of years ago I am a bit concerned about my calcium intake. I was taking supplements in the UK but stopped when there was a report on increased incidence of heart disease. I am eating injera, the local, unique dough that is eaten with everything. It looks like a chamois leather but isn’t too bad and is suppose to have some calcium in it.  Should I get Steve (my husband) to bring some calcium tablets back when he visits the UK in the summer?

Must go as visiting a local community project for orphans. More to come.

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By Andy Beckingham, ex-DPH and public health consultant now living and working in India

Indian back street

Indian back street

I spent much of 2010 in South India on sabbatical with Indian Institute of Public Health. Would my UK experience be useful? Or irrelevant in India? I made new friends and networks, loved the food, the heat and the work. I was incredibly lucky to find a great boss. Found myself helping identify the ‘burdens of disease’ for one state (pop c80 million) and working with the Indian government to focus primary care and work on social determinants, to address health needs – and often failing too. I worked on maternal mortality and discovered how hard it is to change things when social determinants are complex and women undervalued. My boss and I were asked by the government to assess the impact of climate change on the country’s health, and our contribution went into Climate Change and India: a 4×4 Assessment. It helped that I’d been a DPH in England, but getting this kind of work experience was mostly just luck. I returned briefly to a snowy UK, its NHS workforce shell-shocked to find their skills on the Government’s scrapheap. Hmmm – back to India…

2011 – I woke as the dawn appeared as a thin orange line over the Arabian Sea and the plane flew in over the Western Ghats. In 2010 I had met the CEO of a maternity hospital who’d asked if I’d like to set up midwifery training. Are you kidding?? Yes!! So In 2011 I find myself working in a hospital seriously dedicated to improving clinical quality. And in a world of private health care, nevertheless providing free health care for the poorest women. Our Consultant Obstetricians work 7am-9pm and sleep in the hospital when on call, to be quickly available when women have difficulties. A small village hospital 100 km away and run by nuns needed doctors, so our CEO is lending them two registrars for free and I’m helping them plan cervical screening and incontinence counselling to complement their obs & gynae sessions. Public health work here is like…  SO interesting, Dude…  I’ve made links with an NGO in the city’s biggest slum (estimated population… a million? We have no demographic nor epidemiological data) with no primary health maternity care there. Pregnant women walk 3km in 90ᵒF to the nearest private hospital. We plan to provide a free doctor. They’ll have their work cut out…

The maternity hospital I work for managed 5,000 births last year, 65% of them ‘high risk’. We’re developing a programme to train nurses to become professional midwives who will manage the normal births and free the obstetricians up to do the risky ones. India doesn’t really have midwives, so we will pilot their training and work, and evaluate whether they contribute to better maternal outcomes. So in 2011 I find myself writing the curriculum, setting up the training, plus a midwifery exchange programme with South Africa, London and Toronto. Almost every week another really interesting health issue arises. I love it here… want to come too?

PS: Spot the health inequality issues in the photo to win free biryani, bangles and a public health internship.

PPS: No salary available, find your own plane fare.

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Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners.  Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost.  Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the   hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are.  Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base.  But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery.  This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

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